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Facial Plast Surg 2021; 37(06): 790-800
DOI: 10.1055/s-0041-1729632
Original Research

Surgical and Nonsurgical Management of the Nasal Skin-Soft Tissue Envelope

Rakan Saadoun 
1   Ruprecht Karls University Heidelberg, Faculty of Medicine Mannheim, Mannheim, Germany
2   Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Centre Mannheim, Mannheim, Germany
3   Department of Plastic Surgery, University of Pittsburgh, Pittsburgh Pennsylvania
,
Frank Riedel
4   HNO-Zentrum Rhein-Neckar, Mannheim, Germany
,
Alwyn D'Souza
5   Department of Otolaryngology, University Hospital Lewisham, Lewisham, London, United Kingdom
,
Johannes A. Veit
2   Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Centre Mannheim, Mannheim, Germany
4   HNO-Zentrum Rhein-Neckar, Mannheim, Germany
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Abstract

Management of the skin-soft tissue envelope (SSTE) in rhinoplasty is challenging and critical for the overall outcome. The preoperative identification of patients with thick or thin skin and with preexisting skin conditions may contribute significantly to the postsurgical result. Most publications and textbooks focus on the management of the osseocartilaginous framework, but the SSTE management is often not addressed in detail. However, nonsurgical treatments, such as skin preconditioning, topical steroid-injections, oral isotretinoin, and topical vitamin A derivatives, may provide strong benefits. In this article, we reviewed the literature to present a comprehensive review on the available surgical and nonsurgical approaches pre-, intra-, and postoperatively dealing with SSTE in rhinoplasty.

Keywords

rhinoplasty - nasal skin - skin-soft tissue envelope - thin skin - thick skin - isotretinoin - nonsurgical management


Publication History

Article published online:
11 May 2021

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  • References

  • 1 Eggerstedt M, Rhee J, Buranosky M. et al. Nasal skin and soft tissue thickness variation among differing races and ethnicities: an objective radiographic analysis. Facial Plast Surg Aesthet Med 2020; 22 (03) 188-194
    CrossrefPubMedGoogle Scholar
  • 2 Kosins AM, Obagi ZE. Managing the difficult soft tissue envelope in facial and rhinoplasty surgery. Aesthet Surg J 2017; 37 (02) 143-157
    CrossrefPubMedGoogle Scholar
  • 3 Cobo R. Ethnic rhinoplasty. HNO 2018; 66 (01) 6-14
    CrossrefPubMedGoogle Scholar
  • 4 Lai-Cheong JE, McGrath JA. Structure and function of skin, hair and nails. Medicine (Baltimore) 2013; 41 (06) 317-320
    CrossrefPubMedGoogle Scholar
  • 5 Obagi ZE. The Art of Skin Health Restoration and Rejuvenation. Boca Raton, FL: Crc Press; 2014: 1-16
    CrossrefGoogle Scholar
  • 6 Cobo R, Camacho JG, Orrego J. Integrated management of the thick-skinned rhinoplasty patient. Facial Plast Surg 2018; 34 (01) 3-8
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Baumann L. Skin ageing and its treatment. J Pathol 2007; 211 (02) 241-251
    CrossrefPubMedGoogle Scholar
  • 8 Fenske NA, Lober CW. Structural and functional changes of normal aging skin. J Am Acad Dermatol 1986; 15 (4 Pt 1): 571-585
    CrossrefPubMedGoogle Scholar
  • 9 Ozturk CN, Larson JD, Ozturk C, Zins JE. The SMAS and fat compartments of the nose: an anatomical study. Aesthetic Plast Surg 2013; 37 (01) 11-15
    CrossrefPubMedGoogle Scholar
  • 10 Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood supply: an anatomic study validating the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg 1995; 95 (05) 795-799 , discussion 800–801
    CrossrefPubMedGoogle Scholar
  • 11 Saban Y, Andretto Amodeo C, Hammou JC, Polselli R. An anatomical study of the nasal superficial musculoaponeurotic system: surgical applications in rhinoplasty. Arch Facial Plast Surg 2008; 10 (02) 109-115
    CrossrefPubMedGoogle Scholar
  • 12 Letourneau A, Daniel RK. The superficial musculoaponeurotic system of the nose. Plast Reconstr Surg 1988; 82 (01) 48-57
    CrossrefPubMedGoogle Scholar
  • 13 Sun GK, Lee DS, Glasgold AI. Interdomal fat pad: an important anatomical structure in rhinoplasty. Arch Facial Plast Surg 2000; 2 (04) 260-263
    CrossrefPubMedGoogle Scholar
  • 14 Daniel RK, Pálházi P. Rhinoplasty: An Anatomical and Clinical Atlas. Cham, Switzerland: Springer International Publishing; 2018: 1-47
    CrossrefGoogle Scholar
  • 15 Walker A, Joshi A, D'Souza A. Care of the cocaine user with nasal deformity. Facial Plast Surg 2017; 33 (04) 411-418
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Yazdanparast T, Hassanzadeh H, Nasrollahi SA. et al. Cigarettes smoking and skin: a comparison study of the biophysical properties of skin in smokers and non-smokers. Tanaffos 2019; 18 (02) 163-168
    PubMedGoogle Scholar
  • 17 Langton AK, Tsoureli-Nikita E, Merrick H. et al. The systemic influence of chronic smoking on skin structure and mechanical function. J Pathol 2020; 251 (04) 420-428
    CrossrefPubMedGoogle Scholar
  • 18 Ortiz A, Grando SA. Smoking and the skin. Int J Dermatol 2012; 51 (03) 250-262
    CrossrefPubMedGoogle Scholar
  • 19 Chu E, Davis RE. SMAS debulking for management of the thick-skinned nose. JAMA Facial Plast Surg 2015; 17 (04) 305-306
    CrossrefPubMedGoogle Scholar
  • 20 Cho GS, Kim JH, Yeo NK, Kim SH, Jang YJ. Nasal skin thickness measured using computed tomography and its effect on tip surgery outcomes. Otolaryngol Head Neck Surg 2011; 144 (04) 522-527
    CrossrefPubMedGoogle Scholar
  • 21 Çavuş Özkan M, Yeşil F, Bayramiçli İ, Bayramiçli M. Soft tissue thickness variations of the nose: a radiological study. Aesthet Surg J 2020; 40 (07) 711-718
    CrossrefPubMedGoogle Scholar
  • 22 Nouveau-Richard S, Monot M, Bastien P, de Lacharrière O. In vivo epidermal thickness measurement: ultrasound vs. confocal imaging. Skin Res Technol 2004; 10 (02) 136-140
    CrossrefPubMedGoogle Scholar
  • 23 Davis RE, Hrisomalos EN. Surgical management of the thick-skinned nose. Facial Plast Surg 2018; 34 (01) 22-28
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Guyuron B, Lee M. An effective algorithm for management of noses with thick skin. Aesthetic Plast Surg 2017; 41 (02) 381-387
    CrossrefPubMedGoogle Scholar
  • 25 Gruber RP, Shih HB, Lin WC. Commentary on: Managing the difficult soft tissue envelope in facial and rhinoplasty surgery. Aesthet Surg J 2017; 37 (02) 158-160
    CrossrefPubMedGoogle Scholar
  • 26 Ward A, Brogden RN, Heel RC, Speight TM, Avery GS. Isotretinoin. A review of its pharmacological properties and therapeutic efficacy in acne and other skin disorders. Drugs 1984; 28 (01) 6-37
    CrossrefPubMedGoogle Scholar
  • 27 Prevost N, English JC. Isotretinoin: update on controversial issues. J Pediatr Adolesc Gynecol 2013; 26 (05) 290-293
    CrossrefPubMedGoogle Scholar
  • 28 Soleymani T, Lanoue J, Rahman Z. A practical approach to chemical peels: a review of fundamentals and step-by-step algorithmic protocol for treatment. J Clin Aesthet Dermatol 2018; 11 (08) 21-28
    PubMedGoogle Scholar
  • 29 Polcz ME, Barbul A. The role of vitamin a in wound healing. Nutr Clin Pract 2019; 34 (05) 695-700
    CrossrefPubMedGoogle Scholar
  • 30 Xu S, Kwa M, Agarwal A, Rademaker A, Kundu RV. Sunscreen product performance and other determinants of consumer preferences. JAMA Dermatol 2016; 152 (08) 920-927
    CrossrefPubMedGoogle Scholar
  • 31 Hughes BR, Cunliffe WJ. A prospective study of the effect of isotretinoin on the follicular reservoir and sustainable sebum excretion rate in patients with acne. Arch Dermatol 1994; 130 (03) 315-318
    CrossrefPubMedGoogle Scholar
  • 32 Cobo R, Vitery L. Isotretinoin use in thick-skinned rhinoplasty patients. Facial Plast Surg 2016; 32 (06) 656-661
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 iPLEDGE. In; 2016
  • 34 Huang YC, Cheng YC. Isotretinoin treatment for acne and risk of depression: a systematic review and meta-analysis. J Am Acad Dermatol 2017; 76 (06) 1068-1076.e9
    CrossrefPubMedGoogle Scholar
  • 35 Marqueling AL, Zane LT. Depression and suicidal behavior in acne patients treated with isotretinoin: a systematic review. Semin Cutan Med Surg 2005; 24 (02) 92-102
    CrossrefPubMedGoogle Scholar
  • 36 (MD) NIoDaDaKD-B. LiverTox:. Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Updated May 1, 2018
    Google Scholar
  • 37 Goodfield MJD, Cox NH, Bowser A. et al. Advice on the safe introduction and continued use of isotretinoin in acne in the U.K. 2010. Br J Dermatol 2010; 162 (06) 1172-1179
    CrossrefPubMedGoogle Scholar
  • 38 Spring LK, Krakowski AC, Alam M. et al. Isotretinoin and timing of procedural interventions: a systematic review with consensus recommendations. JAMA Dermatol 2017; 153 (08) 802-809
    CrossrefPubMedGoogle Scholar
  • 39 Nemati S, Golchay J, Iranfar K, Alizadeh A. Frequency of acne vulgaris and its exacerbation in facial and periorbital area after septorhinoplasty. Am J Otolaryngol 2013; 34 (05) 378-381
    CrossrefPubMedGoogle Scholar
  • 40 Erol OO. Microfat grafting in nasal surgery. Aesthet Surg J 2014; 34 (05) 671-686
    CrossrefPubMedGoogle Scholar
  • 41 Barone M, Cogliandro A, Salzillo R. et al. The role of skin thickness in the choice of a rhinoplasty technique for thin-skinned patients: analysis of long-term results and patient satisfaction. Aesthetic Plast Surg 2020; 44 (05) 1742-1750
    CrossrefPubMedGoogle Scholar
  • 42 Toriumi DM. Dorsal augmentation using autologous costal cartilage or microfat-infused soft tissue augmentation. Facial Plast Surg 2017; 33 (02) 162-178
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Raghuram AC, Yu RP, Lo AY. et al. Role of stem cell therapies in treating chronic wounds: a systematic review. World J Stem Cells 2020; 12 (07) 659-675
    CrossrefPubMedGoogle Scholar
  • 44 Charles-de-Sá L, Gontijo-de-Amorim NF, Maeda Takiya C. et al. Antiaging treatment of the facial skin by fat graft and adipose-derived stem cells. Plast Reconstr Surg 2015; 135 (04) 999-1009
    CrossrefPubMedGoogle Scholar
  • 45 Rigotti G, Marchi A, Galiè M. et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg 2007; 119 (05) 1409-1422 , discussion 1423–1404
    CrossrefPubMedGoogle Scholar
  • 46 Whitaker EG, Johnson Jr CM. Skin and subcutaneous tissue in rhinoplasty. Aesthetic Plast Surg 2002; 26 (Suppl. 01) S19
    CrossrefPubMedGoogle Scholar
  • 47 Ballin AC, Kim H, Chance E, Davis RE. The articulated alar rim graft: reengineering the conventional alar rim graft for improved contour and support. Facial Plast Surg 2016; 32 (04) 384-397
    Article in Thieme ConnectPubMedGoogle Scholar
  • 48 Dulguerov N, D'Souza A. Update on treatment rationale and options for the ageing face. Curr Opin Otolaryngol Head Neck Surg 2011; 19 (04) 269-275
    CrossrefPubMedGoogle Scholar
  • 49 Daniel RK, Palhazi P. The nasal ligaments and tip support in rhinoplasty: an anatomical study. Aesthet Surg J 2018; 38 (04) 357-368
    CrossrefPubMedGoogle Scholar
  • 50 Cerkes N. The crooked nose: principles of treatment. Aesthet Surg J 2011; 31 (02) 241-257
    CrossrefPubMedGoogle Scholar
  • 51 Cakir B, Oreroğlu AR, Doğan T, Akan M. A complete subperichondrial dissection technique for rhinoplasty with management of the nasal ligaments. Aesthet Surg J 2012; 32 (05) 564-574
    CrossrefPubMedGoogle Scholar
  • 52 Zholtikov V, Golovatinsky V, Palhazi P, Gerbault O, Daniel RK. Rhinoplasty: a sequential approach to managing the bony vault. Aesthet Surg J 2020; 40 (05) 479-492
    CrossrefPubMedGoogle Scholar
  • 53 Daniel RK. Rhinoplasty: dorsal grafts and the designer dorsum. Clin Plast Surg 2010; 37 (02) 293-300
    CrossrefPubMedGoogle Scholar
  • 54 Daniel RK. Rhinoplasty: An Atlas of Surgical Techniques. New York, NY: Springer Science & Business Media; 2013: 227-278
    Google Scholar
  • 55 Cerkes N, Basaran K. Diced cartilage grafts wrapped in rectus abdominis fascia for nasal dorsum augmentation. Plast Reconstr Surg 2016; 137 (01) 43-51
    CrossrefPubMedGoogle Scholar
  • 56 Lo S, Kenway B, Hosni A. Acellular porcine dermal collagen implant in saddle nose deformity. Plast Reconstr Surg 2011; 128 (02) 82e-84e
    CrossrefPubMedGoogle Scholar
  • 57 Bhattacharya R, Das P, Joardar SN. et al. Novel decellularized animal conchal cartilage graft for application in human patient. J Tissue Eng Regen Med 2019; 13 (01) 46-57
    CrossrefPubMedGoogle Scholar
  • 58 Kao W-P, Lin Y-N, Lin T-Y. et al. Microautologous fat transplantation for primary augmentation rhinoplasty: long-term monitoring of 198 Asian patients. Aesthet Surg J 2016; 36 (06) 648-656
    CrossrefPubMedGoogle Scholar
  • 59 Gode S, Ozturk A, Berber V, Kısmalı E. Effect of injectable platelet-rich fibrin on diced cartilage's viability in rhinoplasty. Facial Plast Surg 2019; 35 (04) 393-396
    Article in Thieme ConnectPubMedGoogle Scholar
  • 60 Kovacevic M, Riedel F, Wurm J, Bran GM. Cartilage scales embedded in fibrin gel. Facial Plast Surg 2017; 33 (02) 225-232
    Article in Thieme ConnectPubMedGoogle Scholar
  • 61 Hussein WK, Foda HM. Pollybeak deformity in middle eastern rhinoplasty: prevention and treatment. Facial Plast Surg 2016; 32 (04) 398-401
    Article in Thieme ConnectPubMedGoogle Scholar
  • 62 Garramone Jr RR, Sullivan PK, Devaney K. Bulbous nasal tip: an anatomical and histological evaluation. Ann Plast Surg 1995; 34 (03) 288-290 , discussion 290–291
    CrossrefPubMedGoogle Scholar
  • 63 Daniel RK. The preservation rhinoplasty: a new rhinoplasty revolution. Aesthet Surg J 2018; 38 (02) 228-229
    CrossrefPubMedGoogle Scholar
  • 64 Kosins AM, Daniel RK. Decision making in preservation rhinoplasty: a 100 case series with one-year follow-up. Aesthet Surg J 2020; 40 (01) 34-48
    CrossrefPubMedGoogle Scholar
  • 65 Hoehne J, Brandstetter M, Gubisch W, Haack S. How to reduce the probability of a pollybeak deformity in primary rhinoplasty: a single-center experience. Plast Reconstr Surg 2019; 143 (06) 1620-1624
    CrossrefPubMedGoogle Scholar
  • 66 Slavit DH, Lipton RJ, Kern EB, McCaffrey TV. Rhinolift operation in the treatment of the aging nose. Otolaryngol Head Neck Surg 1990; 103 (03) 462-467
    CrossrefPubMedGoogle Scholar
  • 67 Lemperle G, Biewener A. External skin excision in the sebaceous nose and supratip deformity. Aesthetic Plast Surg 1992; 16 (04) 303-307
    CrossrefPubMedGoogle Scholar
  • 68 Caterson SA, Singh M, Kueckelhaus M, Caterson EJ, Eriksson E. Skin excision as an adjunctive technique to rhinoplasty in middle-aged and elderly patients. Plast Reconstr Surg Glob Open 2015; 3 (10) e532-e532
    CrossrefPubMedGoogle Scholar
  • 69 Michelson LN, Peck Jr GC, Kuo HR. et al. The quantification and distribution of nasal sebaceous glands using image analysis. Aesthetic Plast Surg 1996; 20 (04) 303-309
    CrossrefPubMedGoogle Scholar
  • 70 Warner JP, Chauhan N, Adamson PA. Alar soft-tissue techniques in rhinoplasty: algorithmic approach, quantifiable guidelines, and scar outcomes from a single surgeon experience. Arch Facial Plast Surg 2010; 12 (03) 149-158
    CrossrefPubMedGoogle Scholar
  • 71 Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepancies in rhinoplasty. Plast Reconstr Surg 1996; 97 (03) 643-648
    CrossrefPubMedGoogle Scholar
  • 72 Sharif-Askary B, Carlson AR, Cornejo A, Berkowitz RL, Marcus JR. Perioperative practice patterns for rhinoplasty: faculty speakers from the first international meeting of rhinoplasty societies. Plast Reconstr Surg 2020; 145 (05) 1013e-1015e
    CrossrefPubMedGoogle Scholar
  • 73 Ghavimi MA, Taheri Talesh K, Ghoreishizadeh A, Chavoshzadeh MA, Zarandi A. Efficacy of tranexamic acid on side effects of rhinoplasty: a randomized double-blind study. J Craniomaxillofac Surg 2017; 45 (06) 897-902
    CrossrefPubMedGoogle Scholar
  • 74 Sanober A, Rashid M, Khan MI. et al. Use of steroids in rhinoplasty with lateral osteotomies for reducing postoperative oedema. J Ayub Med Coll Abbottabad 2018; 30 (01) 45-48
    PubMedGoogle Scholar
  • 75 Apaydin F, Stanic L, Unadkat S, Saleh HA. Postoperative care in aesthetic rhinoplasty patients. Facial Plast Surg 2018; 34 (06) 553-560
    Article in Thieme ConnectPubMedGoogle Scholar
  • 76 Ong AA, Farhood Z, Kyle AR, Patel KG. Interventions to decrease postoperative edema and ecchymosis after rhinoplasty: a systematic review of the literature. Plast Reconstr Surg 2016; 137 (05) 1448-1462
    CrossrefPubMedGoogle Scholar
  • 77 Irvine LE, Nassif PS. Use of 5-fluorouracil for management of the thick-skinned nose. Facial Plast Surg 2018; 34 (01) 9-13
    Article in Thieme ConnectPubMedGoogle Scholar
  • 78 Hanasono MM, Kridel RW, Pastorek NJ, Glasgold MJ, Koch RJ. Correction of the soft tissue pollybeak using triamcinolone injection. Arch Facial Plast Surg 2002; 4 (01) 26-30 , discussion 31
    CrossrefPubMedGoogle Scholar
  • 79 Papel ID, Frodel JL, Holt GR. et al. Facial Plastic and Reconstructive Surgery. In: Ira D. Papel JLF, G. Richard Holt, Wayne F. Larrabee Jr., Nathan E. Nachlas, Stephen S. Park, Jonathan M. Sykes, Dean M. Toriumi. eds, Facial Plastic and Reconstructive Surgery. 4th edition. New York: Thieme; 2016
    Google Scholar
  • 80 Thomas WW, Bucky L, Friedman O. Injectables in the nose: facts and controversies. Facial Plast Surg Clin North Am 2016; 24 (03) 379-389
    CrossrefPubMedGoogle Scholar
  • 81 Shafir R, Cohen M, Gur E. Blindness as a complication of subcutaneous nasal steroid injection. Plast Reconstr Surg 1999; 104 (04) 1180-1182 , discussion 1183–1184
    CrossrefPubMedGoogle Scholar
  • 82 Wang LL, Friedman O. Update on injectables in the nose. Curr Opin Otolaryngol Head Neck Surg 2017; 25 (04) 307-313
    CrossrefPubMedGoogle Scholar