RHINOPLASTY IN THE THICK-SKINNED NOSE and THE patient

,
RHINOPLASTY
By
IN THE THICK-SKINNED
NOSE
FERNANDO ÜRTrztMONASTERIO, M.D., JOAQUIN LOPEZ-MAS,
JOAQUIN ARAICO, M.D.
M.D.,
and
plastic and Reconstructiue Surgery Unit, Hospital General and the Graduate Division 01 the
Universidad Nacional Autonoma de Mexico, Apartado 7I068, Mexico 7, D.F.
patient with a thickened nasal skin presents surgical problems and a carefully
planned and executed rhinoplasty does not necessarily produce the expected result
(Webster, 1967; Millard, 1969). The skin does not adapi to the osteocartilaginous
framework and the nose remains thickened and bulbous; the thicker the skin the more
dífficult it is to obtain a good resulto Secondary deformities of these areas are very
common in this group of patients, and the recommended correction by trimming the
lateral cartilages does little to improve their appearance. Some experienced surgeons
refrain from doing either a primary or a secondary rhinoplasty in a person with a thickskinned nose (Rees et al., 1970).
A number of techniques have been described to remove some of this excessive1y
thick skin from the lower half of the nose. Direct sculpturing of the alar margins by
means of wedge-shaped skin excision at different sites can be of great value (Millard,
1960, 1967). Dr G. V. Webster (personal communication) advocates an S-shaped
excision of dorsum skin, starting at the bridge and ending at the columella.
AlI of these procedures singly or in combination, however, tend to interfere with
the lymphatic drainage of the skin, resulting in chronic oedema. The nos e remains
swollen for a long time post-operativelyjthe nasal tip is indurated and the final result
is not much better than the original condition.
Comparative histological examination of the nasal skin in these patients shows a
reasonably normal structure in the upper half, corresponding to the bony dorsum (Fig. 1).
Much thicker skin, -with more abundant and larger-than-normal sebaceous glands is
found in the tip and the supra-tip areas. Thé appearance is similar to that of a moderate
degree of rhinophyma (Fig. 2), and the excellent results obtained in patients with
rhinophyma in our Unit by partial thickness excision of skin suggested the possible
indication of this procedure for the treatment of the thick-skinned nose.
THE
MATERIALS AND METHODS
A total of 37 patients with thick-skinned noses requesting rhinoplasty are inc1uded
in this study. Eight of them had had a previous conventional operation with poor post"operative results.
Four patients had an obviously msuikient skeletal framework
requiring correction; in 2 this was the result of previous excessive hump remo val. The
remaining 25 were primary cases.
.
. Partial excision of the skin was done with an electrical dermabrader (Fig. 3). . In a.
few of the early cases, a scalpel was used with a final polishing from the dermabrader.
A variable amount of skin was shaved from the tip, the alar region and the columella,
care being taken to leave the base of the sebaceous glands to assure epithelial regeneration
and protect the cartilaginous framework. In order to obtain a more homogeneous colour
over the whole nose, the upper half was dermabraded very superficially.
In 29 cases, a conventional rhinoplasty was simultaneously performed and in 4 of
them an iliac bone graft to the dorsum was inserted at the same stage.
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FIG.
1.
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OF PLASTIC
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Section of skin from the upper half of the nasal dorsum. Skin appendages are
c1early seen in normal amounts and dimensions.
FIG. 2. Biopsy from the lower half of the nasal dorsüm. Considerable enlargement of
sebaceous glands comparable with incipient rhinophyma. (Same magnification as Figure 1.)
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RHINOPLASTY
IN
THE
THICK-:.SKINNED
NOSE
21
When only dermabrasion was performed, the wound was covered in the convenúonal manner. " A layer of fine mesh gauze was directly applied to the dermabraded area
and covered with another layer óf gauze which was removed after 24 hours; allowing
the fine mesh gauze to form a dry cover.
FIG. 3. Type of electrical dermabrader
decortication.
used for nasal
Fine mesh gauze
1 cm strips
FIG. 4. Schematic representation of dressing applied to the nose
following rhinoplasty and simultaneous dermabrasion of the thick
skin on the nose.
In the cases associated with rhinoplasty or bone graft, the dermabrasion was done
as the end stage of the procedure. Strips of fine mesh gauze, 1 cm in width, were used
over the skin following the pattern of tape application in the usual rhinoplasty. This
was covered with compressed cotton on top of which the usual plaster of Paris was
applied. The absorbable layer of cotton prevented maceration, and also the easy removal
of the cast every 4 or 5 days (Fig. 4).
(.
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FIG. 5. A, Pre-opesative photograph of girl aged 16. B, Profile 3 months after conventional
rhinoplasty and mentoplasty, Patient and surgeon unhappy. e and D, Final results 2
months after dermabrasion.
RHINOPLASTY
IN
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THICK-SKINNED
NOSE
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RESULTS
The result was considered excellent when there was no scarring, no discoloration
and both patient and doctor were pleased (Figs. 5 and 6). Results were considered fair
when the skin pores were markedly visible and poor when there was a noticeable scar
or an irregularity of the skin surface.
FIG. 6. A and B, Pre-operative photographs of male aged 18 with a history of septoplasty at age
10. Moderate skeletaldepression at lower half of the nose, associated with thick skin. e and D, Postoperative results, following rhinoplasty, cartilage grafting to columella and simultaneous dermabrasion.
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In our senes there were 25 patients in whom results were considered excellent
while 8 had fair results. Four were considered poor; 1 had a visible scar, and 3 an
irregular skin surface. The bad results obtained in these last 4 cases cannot be attributed
to the procedure itself, but to inadequate technique. The procedure should be used only
by surgeons with a considerable experience, since it requires sound judgment to evaluate
the problem, and a considerable technical skill.
No complications occurred when the procedure was associated with bone or cartilage
grafting.
SUMMARY
The results of dermabrasion of the nose for correction of the thick skin are presented.
The procedure was associated in some cases with simultaneous rhinoplasty and
with bone grafting to the dorsum.
. .
This new application of an old technique has been followed by good results in wellselected cases. Poor results were related to inadequate judgment or poor technique,
REFERENCES
MILLARD,D. R. (1960). External excisions in rhinoplasty. British Journal o/ Plastic
Surgery, 12, 34°-348.
MILLARD,D. R. (1967). Alar margin sculpturing. Plastic and Reconstructive Surgery, 40,
337-342.
MILLARD,D. R. (1960). Secondary corrective rhinoplasty. Plastic and Reconstructioe
Surgery, 44, 545-557·
REES,T. O., KRUPP,S. and WOOD-SM1TH,D. (1970). Secondary rhinoplasty. Plastic and
Reconstructioe Surgery , 46, 332-34°.
WEBSTER,G. V. (1967). Random reflections in rhinoplasty. Plastic and Reconstructive
Surgery, 39, 147-152.
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