Patients who have excess skin thickness related to sebaceous hypertrophy would benefit from alteration in diet, use of Retin A, and on rare occasions, treatment with Isotretinoin.
Patients who have excess skin thickness related to thick dermis will incur thinning of the skin over the years if the underlying frame is firm and stable.
In a small percentage of patients, the amorphous tip configuration is related to the extra fat in between and overlying the domes. To correct this condition, the extra fat is removed, leaving the dermis and a small amount of subdermal fat intact.
Another crucial step in achieving an optimal rhinoplasty outcome in patients with thick skin is elimination of any dead space.
A supratip stitch is routinely used on such a patient in order to approximate the supratip skin to the underlying dorsal frame.
One of the anatomical variations that add to the complexity of rhinoplasty is excessive thickness of the nose skin, where achieving optimal tip definition becomes more taxing. Excess skin thickness can result from sebaceous overactivity or inherent thickness of the dermis. The latter represents more of a challenge. There is a difference in the quality of the skin between the patients in Figures 16.1 and 16.2 . The patient in Figure 16.1 has large pores and significant sebaceous activity, which can, to a large degree, be controlled by a combination of diet, the use of Retin A and, if necessary, isotretinoin. In contrast, the skin of the patient in Figure 16.2 cannot be altered by these measures. Isotretinoin is not an innocuous drug and should be prescribed under the supervision of a dermatologist. It is detrimental to healing and may cause scar hypertrophy if surgery is performed while the patient is on this medication. It is, therefore, advisable to delay surgery until 6 months after cessation of isotretinoin treatment. Additionally, the use of laser or dermabrasion could be beneficial to patients with sebaceous hyperplasia. Here again, one has to avoid using lasers or dermabrasion for 1 year after treatment with isotretinoin. A better option is to proceed with laser treatment or dermabrasion prior to the use of isotretinoin.
A more difficult example of a patient with thick skin is illustrated in Figure 16.2 . This patient has a thick dermis with fewer sebaceous glands. The skin is somewhat red and shiny. The solution in this group of patients is establishment of a firm underlying frame to create reasonable nose definition. The firmer the nose frame, the more likely it is that the skin will become thinner over a period of years and the definition will be close to optimal.
One factor that contributes to the amorphous tip is the presence of extra fat lying between the domes and perhaps overlying them. To correct this unfavorable anatomical presentation, excess fat is removed using an open technique. A columellar incision is made and a healthy nasal tip skin flap is elevated, leaving the excess subcutaneous fibrofatty tissues over the lower lateral cartilages and the part between the domes attached to the underlying frame. After the skin flap is adequately mobilized, the frame is denuded by removing excessive fibrofatty tissue ( Figures 16.3, 16.4 ). It is crucial to ensure that the skin flap is not defatted, since this may not be safe. The flap will still contain the dermis and a small layer of subdermal fat. One must be cautious when performing this operation on current or previous heavy smokers.
The second step in obtaining a successful outcome in a patient who has thick nose skin is creation of a firm cartilaginous frame. Commonly, spreader grafts are placed, utilizing either a firm piece of cartilage from the septum or costal cartilage. The lateral crura are strengthened with a lateral crura strut. A columella strut is inserted and the domes are approximated. When the tip is rotated cephalically, a 5-0 nylon suture is used to fix the medial crura to the caudal septum to avoid rotation of the tip due to the heavy weight of the skin, as described in Chapter 4 . Any gap between the cartilaginous structures, where overlying skin can appose the nasal lining, is eliminated. This way, essentially every segment of the nasal soft tissue is juxtaposed to cartilage or bone.
The next step in achieving an optimal rhinoplasty outcome in patients with thick skin is the elimination of dead space. A supratip stitch is routinely used on such patients in order to approximate the supratip skin to the underlying dorsal frame. To place this stitch, the skin is draped over the frame and the columellar incision is temporarily approximated using a single stitch of 6-0 fast-absorbable catgut. A 25 gauge needle is dipped in methylene blue or brilliant green and the supratip break site is tattooed, trying to ensure that the underlying anterocaudal septal angle is marked with the tattooing medium ( Figure 16.5 ; see Video 4.24a in Chapter 4 ). A 6-0 poliglecaprone or 5-0 polyglactin suture is passed through the subcutaneous tissue, catching a small amount of fat (guided by the tattoo mark), passed through the anterocaudal septum (guided by the tattoo mark), and tied gently enough to merely approximate the subcutaneous fat to the underlying frame ( Figure 16.6 ). This stitch can cause necrosis of the overlying skin if it is tied too tightly. It is therefore essential to tie the knot very loosely. In patients with significantly thick skin, a similar stitch may be used to approximate the skin to the underlying lateral crura of the lower lateral cartilages. If there is redundant skin overlapping at the columella incision site, it is trimmed and tapered laterally along the original alar incision to minimize the potential for excessive postoperative dead space, which encourages swelling, formation of scar tissue, and loss of tip definition ( Figure 16.7 ). These maneuvers are effective and sometimes even result in excessive definition of the nose as demonstrated in Figure 16.8 ( Box 16.1 ; Animation 16.1). Another patient who exhibits even thicker skin is illustrated in Figure 16.9 ( Box 16.2 ; Animation 16.2).