Richard E. Davis, MD FACS - The Center for Facial Restoration in Miramar, Florida

The Importance of Nasal Skin in Rhinoplasty

Nasal shape is governed in large part by the size and shape of the underlying nasal skeleton. As a consequence, cosmetic rhinoplasty is largely directed at modifying the underlying skeletal contour in order to achieve a more desirable external appearance. However, because the skeletal framework is covered by skin and subcutaneous tissues such as muscle and fat, the shape of the raw nasal skeleton has very little resemblance to the familiar appearance of the outer nose. Since the overlying skin serves to smooth, soften, conceal and reshape the skeletal framework, and because it affects some areas more than others, the transforming effects of the skin must be factored into each skeletal modification if the desired nasal contour is to materialize. While the skin itself is seldom modified in cosmetic rhinoplasty, the surgical importance of the outer "skin-soft tissue envelope" cannot be understated. And for some patients, skin effects are far more difficult to predict or to control.

Perhaps the single most important surgical characteristic of the nasal skin is its overall thickness. Nasal skin of intermediate thickness with a smooth and healthy complexion is by far the most amenable to cosmetic rhinoplasty, whereas skin types at the extremes of thickness – too thick or too thin – are the least favorable. Scarring tendencies and skin elasticity are two other important factors which can profoundly influence the surgical prognosis.

The Implications of Thin Skin in Rhinoplasty

For patients with ultra-thin skin, incisions tend to heal with minimal scarring and surgical swelling usually resolves promptly, but ultra-thin skin does a poor job of concealing imperfections in the underlying skeletal framework. Even minor skeletal imperfections are readily apparent to inspection, as ultra-thin skin offers only slightly more camouflage than wet tissue paper. Another disadvantage of thin skin is the tendency to shrink following surgical manipulation. The process of post-operative scar contracture, sometimes called the "shrink-wrap" phenomenon, can forcefully distort the nasal framework, leading to progressive and unsightly deformities. For this reason, the greatest surgical challenge in patients with exceptionally thin skin is achieving a flawlessly smooth and sturdy skeletal framework; or if that isn’t possible, artificially increasing skin thickness to better conceal underlying skeletal imperfections. Nasal skin can be artificially thickened in some patients with the addition of subcutaneous blanket grafts fashioned from living dermis, fascia, or perichondrium, but graft survival requires a healthy cutaneous blood supply. Thin skin is also more prone to redness and spider vein formation, although vascular laser treatments are often effective at eliminating these problems after surgery.

Thick Skin: A Significant Challenge in Cosmetic Rhinoplasty

In contrast to the thin-skinned nose, extremely thick nasal skin conceals all but the most obvious imperfections of the underlying nasal skeleton. However, the advantages of ultra-thick skin end there. In fact, ultra-thick nasal skin is often regarded as one of the most challenging, and sometimes insurmountable, obstacles in cosmetic rhinoplasty. The reasons for this unfavorable reputation are numerous, and the hazards of thick nasal skin have prompted many surgeons to avoid treating this challenging patient population altogether.

Bulky Skin and Hidden Nasal Definition

One reason thick nasal skin presents such a formidable challenge is its sheer physical bulk. Bulky skin reduces nasal definition by masking the underlying skeletal framework. Because desirable topographic features of the nasal skeleton are obscured, the delicate surface undulations that characterize a well-defined and attractive nose are lost. Moreover, a weak and underprojected cartilage framework, which is common to thick-skinned noses, only serves to exacerbate the loss of surface highlights.

The Importance of Structural Support in Patients with Thick Nasal Skin

In addition to skeletal masking, ultra-thick nasal skin also burdens the cartilage framework with added weight relative to a thin nasal covering. Surgical modifications that weaken structural support are risky, especially in thick-skinned noses, since progressive skeletal collapse and nasal deformity often result. Instead, cosmetic modifications are best achieved while simultaneously preserving and/or reinforcing structural support. This ensures an attractive and sturdy nasal framework that can handle the added weight of bulky nasal skin. Indeed, without a sturdy and structurally secure cartilage framework, a stable and more refined nasal contour is virtually impossible in the thick-skinned patient. Although rigid skeletal support does not by itself assure a more beautiful nose, a strong nose with ample structural support is the first and foremost requirement for cosmetic enhancement in the thick-skinned patient.

Stretching Nasal Tip Skin to Refine Surface Contour

In addition to safeguarding against structural collapse, a rigid (and well-proportioned) skeletal framework also plays another important role in cosmetic nasal surgery of the thick-skinned nose. It facilitates stretching of the nasal tip skin to further refine the surface contour. Stretching the nasal tip skin over a stiff, better-proportioned, and slightly larger skeletal framework improves surface definition by tightening, and thus thinning, the bulky skin envelope. Although stretching thick nasal skin over a reinforced cartilage framework can potentially improve surface highlights, cosmetic gains are impossible without a pliant skin envelope. Indeed, without adequate skin elasticity, forceful attempts to stretch the skin envelope may create excessive skin tension and produce unwanted skeletal distortion or impaired blood flow. On the other hand, in the thick-skinned nose with highly elastic skin, aggressive skin stretching can sometimes produce dramatic improvements in surface shape and definition. A careful pre-operative assessment of skin distensibility should be conducted in all thick-skinned noses, especially in the revision rhinoplasty patient.

Although a taut skin envelope is an important tool in the treatment of the thick-skinned nose, it is not without potential risk. Excessive skin tension may restrict cutaneous blood flow, resulting in circulatory compromise or even pressure necrosis when the nasal skin is stretched too tightly. While skin necrosis is extremely rare, the risk of tension-induced skin necrosis is increased by pre-existing factors that impair nutrient blood flow, such as tobacco use, microvascular disease (e.g. diabetes), cocaine-induced vascular compromise, or previous surgical scarring. Additional factors that may compromise cutaneous blood flow include excessive use of electrocautery, reckless or extensive tissue dissection, and overly tight compression dressings. In patients with thick, scarred, and inelastic skin, particularly those with one or more risk factors for circulatory compromise, aggressive skin stretching should be avoided in order to prevent excessive skin tension and impaired blood flow. For the rhinoplasty patient with an undersized nose, skeletal enlargement may be cosmetically desirable, but prohibited by a lack of skin distensibility. In these patients, staged surgeries may be required to safely achieve nasal augmentation in a gradual, step-wise manner.

Although the cosmetic benefits of taut and tightly adherent nasal tip skin are undeniable, by necessity, stretching the nasal skin mandates enlarging the nasal framework. While many thick-skinned patients can benefit from a better-projected nasal tip or a slightly longer nose, improving tip definition will sometimes require a nose that is aesthetically too large for the face. Although this dilemma has no easy answers, an artfully proportioned and well defined, if slightly oversized nose, is generally preferable to a smaller yet amorphous one. Said another way, an oversized but otherwise attractive nose is almost always preferable to an unattractive, but smaller one. Shape is almost always more important than size.

Prolonged Surgical Swelling and Inflammation in Thick-Skinned Patients

In addition to its bulk and added weight, ultra-thick nasal skin is also far more prone to surgical swelling and inflammation. In nearly all thick-skinned rhinoplasty patients, surgical swelling requires at least 12-18 months for complete resolution. Because swelling and distortion are prolonged, the true impact of a cosmetic rhinoplasty is usually not evident for at least a year. Delays are even longer for patients undergoing revision surgery or for those with a history of prior nasal inflammation arising from acne, allergic rhinitis or previous nasal injury. In addition, most thick-skinned patients are prone to abnormal fibrotic thickening of the subcutaneous tissues, particularly in patients with thick, sebaceous nasal skin. In this subset of challenging patients, surgical enhancements to the nasal contour may be negated by fibrotic thickening of the already bulky nasal skin. Although topical and/or injectable steroids can reduce or even prevent subcutaneous fibrosis, treatment must be continued until all signs of scar formation subside, sometimes requiring months or years. In rare but severe cases, uncontrolled scar formation can cause obliteration of the nostril openings and irreversible cosmetic disfigurement despite available treatments. Fortunately, these cases are exceedingly rare.