Aesth Plast Surg
DOI 10.1007/s00266-017-0779-1
ORIGINAL ARTICLE
An Effective Algorithm for Management of Noses with Thick Skin
Bahman Guyuron1 • Michelle Lee2
Received: 27 November 2016 / Accepted: 20 December 2016
Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2017
Abstract
Background Thicker nasal skin blunts the definition of the
underlying osseocartilaginous frame and the delicate
topography of the nose posing additional challenges in
producing desirable tip definition. Despite the recognized
challenge in this patient population, there is a paucity of
literature on how to overcome this problem.
Purpose The goal of this article is to provide a systematic
algorithm to manage patients with thick nasal skin.
Method Approach to the thick nasal skin patient begins with
an evaluation of the etiology of their skin thickness. Skin
thickness secondary to sebaceous overactivity is diminished
with the use of retinoic acid derivatives, lasers or isotretinoin
(Accutane), commonly under the advice of the dermatologist.
Rhinoplasty maneuvers include open technique, raising a
healthy and reasonably thick skin flap overlying the tip,
removing the remaining fat overlying and between the domes,
creating a firm cartilaginous frame and eliminating dead
space using the supratip suture reported by the senior author,
and trimming redundant nasal skin envelope when indicated.
Conclusion This systematic approach has been greatly
effective in achieving often predictable and aesthetically
pleasing rhinoplasty results.
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these evidence-based medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
& Bahman Guyuron
bahman.guyuron@gmail.com
1
Case School of Medicine, 29017 Cedar Road, Cleveland, OH,
USA
2
Dupage Medical Group, Warrenville, IL, USA
RHINOPLASTY
Keywords Rhinoplasty
Thick skin
Algorithm
Introduction
The final shape of the nose in rhinoplasty is determined by
the interaction between the underlying nasal framework
and overlying nasal covering. Nasal skin thickness and
quality, therefore, is one of the most important preoperative
factors that can influence the aesthetic outcome of rhino-
plasty. The ideal skin for an optimal rhinoplasty outcome is
intermediate thickness. Skin that is too thin will show all
the imperfections of the underlying nasal frame. In addi-
tion, ultrathin skin can scar and contracture aggressively
post-rhinoplasty. Despite these disadvantages, nasal tip
definition is more easily achieved in individuals with a thin
nasal skin compared to individuals with thicker skin
envelopes. Although a thicker skin envelope can camou-
flage minor imperfections of the underlying nasal frame-
work, patients with thicker nasal skin present greater
difficulty in achieving tip definition [1]. Thicker nasal skin
reduces the definition of the underlying osseocartilaginous
frame. The bulk of the thicker skin in turn weighs on the
underlying cartilage frame which is often weaker in indi-
viduals with thicker nasal skin.
The interplay of the added weight of the nasal skin with a
weak cartilaginous frame exacerbates the loss of definition
in cosmetic rhinoplasty due to the reduction in tip projection.
Further, individuals with thick and sebaceous skin may
experience prolonged nasal tip edema and inflammation
which may lead to scar tissue formation, supratip deformity,
and unfavorable aesthetic outcomes. A combination of thick
nasal skin and over-projected nose is a notorious setup for
the development of a supratip deformity if precaution is not
exercised and special maneuvers are not performed.
Although thick nasal skin is a recognized challenge in
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Fig. 1 Improvement in both
nasal skin thickness and overall
facial skin quality after skin care
and Retin A
Fig. 2 Removal of excess fibro fatty connective tissue between the
nasal domes
rhinoplasty, there is a paucity of information in the literature
regarding how to approach such a patient. The goal of this
article is to present a systematic algorithm to approaching a
rhinoplasty patient with thick nasal skin.
Evaluation and Treatment of the Skin
The most important aspect of the care for rhinoplasty with
thick skin starts with recognition of the condition. Specific
attention should be given to the skin pigmentation, the
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Aesth Plast Surg
consistency of the skin, the porosity of the skin, and the
abundance and overactivity of sebaceous glands within the
skin. Not only does skin quality vary greatly between
patients, it also varies within the same patient at different
stages of life. Studies have shown that the nasal skin is the
thickest at the radix and nasal tip. It is thinner at the rhinion
and columella. Lessard et al. [2] measured skin thickness at
an average of 1.25 mm over the radix and an average of
0.6 mm at the rhinion. Cho et al. measured nasal skin
thickness using preoperative computed tomography scans
in 77 patients undergoing rhinoplasty. The group found that
average nasal skin thickness was 3.3 mm for radix, 2.4 mm
for the rhinion, 2.9 mm for nasal tip, and 2.3 mm for
columella [1]. In addition to the dermal thickness of the
skin, the abundance of sebaceous glands within the skin
plays a critical role in the quality of the skin. Nasal skin in
the supratip area typically contains more sebaceous glands
than nasal skin in other parts of the nose. Although the
number of sebaceous glands in an individual remains rel-
atively constant, the activity of the sebaceous gland varies
during different phases of an individual’s life. For example,
in teenagers, the overactivity of the sebaceous glands can
make achievement of ideal tip definition difficult. It is
important to distinguish whether the underlying cause of
thick skin is due to dermal thickness or sebaceous over-
activity as the treatment varies between the two. Clinically,
skin with sebaceous overactivity is porous and oily, and
skin with thick dermis but few sebaceous glands is less
porous, somewhat red and shiny.
Aesth Plast Surg
Fig. 3 Creating a rigid frame by reinforcing with cartilage grafts.
The lateral crus will also be shortened at the distal ends
Treatment of Sebaceous Thick Skin
Treatment of thick skin due to overabundance or overac-
tivity of sebaceous glands should target specifically at the
activity of the sebaceous glands. The sebaceous gland is
embryologically closely related to the hair follicle and
epidermis. The number of sebaceous gland remains con-
stant throughout one’s life; however, the size and activity
of those glands are influenced by the amount of circulating
androgens, estrogens, glucocorticoids, and prolactin in
one’s body [3]. There is some evidence to suggest that a
Western diet is linked to metabolic alterations that affect
sebaceous glands homeostasis. Food classes that should be
avoided are hyperglycemic carbohydrates, milk, dairy
products, saturated fats, and trans fats. These food classes
promote diet-induced insulin growth factor signaling (IGF-
Fig. 4 Supratip stitch
a transcutaneous marking with
the methylene blue.
b Placement of the
polyglecaprone suture between
the roof of the tip and septum
for obliteration of the dead
space in the supratip
1). Elevated levels of IGF-1 suppress the transcription
factor forkhead box O1 (FoxO1), which is a negative
coregulatory of androgen receptor [4].
In addition to diet alteration, medical treatment of thick
skin due to overactivity of sebaceous glands or sebaceous
hyperplasia includes a meticulous skin care regimen as well
as use of retinoids, a class of medication that inhibits
sebaceous gland activity. Patients should first trial topical
treatment with Retin A and if the quality of the skin does not
improve, oral retinoids such as isotretinoin can be prescribed
under the care of a dermatologist [5] (Fig. 1). Isotretinoin
delays healing; therefore, any invasive maneuvers such as
dermabrasion, laser, or surgery should be delayed for at least
one year. However, rhinoplasty could be considered about
6 months following termination of the treatment. In contrast
to patients with a sebaceous thick nasal envelope, patients
with thick skin due to increased dermal thickness would not
respond as well to skin care treatments. These patients are
treated with rhinoplasty maneuvers.
Removal of Fat Between the Domes
In thick dermal skin patients, there is often extra fat between
and overlying the nasal domes. Removal of the fat decreases
the bulk within the nasal tip. Through a transcolumella
incision, the nasal skin is elevated at the sub-SMAS plane.
The nasal flap thinning includes excision of the SMAS but
not the subcutaneous fat. It is important to make sure the
nasal skin flap is of adequate thickness consisting of dermis
and a small amount of subcutaneous fat. The excess subcu-
taneous fibrofatty tissue should be left over the lower lateral
cartilages. Defatting of the nasal flap should not be per-
formed as this may compromise the vascularity of the skin
flap especially in previously heavy smokers. Once the nasal
skin envelope is elevated, the extra fat between the domes is
removed, skeletonizing the underlying frame (Fig. 2).
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Fig. 5 a–d After redraping at
the end of the rhinoplasty
procedure, the excess nasal skin
envelope is trimmed
Creation of a Rigid Underlying Nasal Frame
In addition to removing the excess fat between the domes, it
is critical for patients with thick dermal nasal skin to have a
strong, firm underlying cartilaginous frame. The goal is for
the rigid frame to gradually exert constant and gentle pres-
sure over the thick dermis. Over a period of years, the
dermis will become thinner and reveal more of the under-
lying definition. In addition, a strong frame will be able to
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Aesth Plast Surg
resist the weight of the thick nasal skin envelope. To create a
firm frame, the existing cartilaginous frame needs to be
reinforced by rigid cartilaginous grafts to support the tip. For
the lateral crura, lateral crura strut grafts are placed to
strengthen the lower lateral cartilages. The medial crura is
strengthened with a columella strut graft. The stability of the
domes is further secured with a subdomal graft [6]. In
addition to the cartilage grafts, tip sutures also have a great
role in creating a firmer bed including the transdomal and
Aesth Plast Surg

b Fig. 6 Before and after photograph of a 62-year-old female patient

with thick skin over 1 year after rhinoplasty

interdomal sutures, described by the senior author in 2000

[7]. Furthermore, to prevent the weight of the skin from
derotating the tip, the medial crura is fixed to the caudal
septum with 5–0 nylon after excision of a triangle piece of
cartilage from the caudal septum and the proportional
amount of the membranous septum on patients who possess
a long nose. It is crucial to set the tip at least 8 and some-
times 10 mm anterior to the dorsum. Additionally, the tip
frame width should not exceed 8 mm on these patients while
on patients with average nasal tip skin this width is usually
set 9–10 mm (Fig. 3).

Elimination of Dead Space

After creation of a rigid cartilaginous frame, it is important

to eliminate all of the dead space between the skin and the
underlying framework. Elimination of dead space prevents
accumulation of the blood, decreases swelling, and pre-
vents formation of fibrofatty tissues causing loss of tip
definition, and the supratip deformity.
To eliminate the dead space and approximate the skin
envelope to the underlying frame, a supratip stitch should be
used. To place the supratip stich, the nasal skin is draped
over the nose. The transcolumella incision is temporarily
closed with a single 6–0 fast absorbing gut suture. A
25-gauge needle is dipped in methylene blue, and the
desired supratip break site is temporarily tattooed, making
sure that the underlying anterocaudal septal angle is marked
with the methylene blue. The skin envelope is then elevated,
and using the tattoo as a guide, a 6–0 polyglecaprone suture
is passed through the deep subcutaneous tissue, passed
through the anterocaudal septal angel, and tied gently to the
underlying frame. This stitch should not be tied too tightly as
it may cause necrosis of the overlying skin (Fig. 4a, b). This
can also be done to approximate the skin to the underlying
lateral crura of the lower lateral cartilages. Similar sutures
could be used to approximate the skin overlying the lateral
crura to the underlying cartilages.

Removal of the Redundant Skin Envelope

In order for the firm underlying nasal frame work to assert

gentle but constant pressure over the overlying skin
envelope to thin the dermis over time, the nasal skin
envelope must fit the underlying nasal frame. Following
alterations to the nasal framework, the nasal skin envelope
is redraped over the frame work. If there is any excess skin

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 Aesth Plast Surg

b Fig. 7 Before and after photograph of a 48-year-old male patient

with thick skin and an over-projected nose 12 months after
rhinoplasty and sliding osteotomy type genioplasty

overlapping at the columella incision, it is trimmed fol-

lowing the incision pattern and tapered laterally along the
original alar incision. It is important to only trim the
redundant tissue. The incision closure at the columella and
the alar rim with 6-0 plain catgut should remain tensionless
(Fig. 5).

Postoperative Care

In patients with thick nasal skin, postoperative taping is

essential; however, it is important to not tape or have the
splint compress the nose too tightly. The taping helps to
compress the skin envelope to the underlying framework.
The nose is taped after work hours and on the weekends for
30–60 days and sometimes longer. The taping should
incorporate the supratip area and avoid the defined area of
the tip itself. The effects of nasal taping have been
demonstrated recently by Ozucer et al. In a randomized
controlled trial of 57 patients, 4 weeks of post-rhinoplasty
taping significantly decreased postoperative edema in the
thick skin patient population. Compared to the control
group of no taping, 4 weeks of post-rhinoplasty taping had
a significant effect on the supratip area but no effect on the
tip [8].
If supratip fullness develops postoperatively, 0.1–0.2 ml
of triamcinolone 40 lg/ml can be administered every
6 weeks until the intended definition is achieved. The
injection should be placed between the dorsal frame and
the soft tissue and not into the dermis. Injection into the
dermis may cause dermal irregularity and telangiectasis
(Figs. 6, 7).

Conclusion

While patients with thick nasal skin present enormous

challenges in rhinoplasty, following a systematic algorithm
of evaluating the etiology of their skin thickness, proper
skin care, removing the fat between and overlying the
domes, creating a firm cartilaginous frame and elimination
of dead space, and trimming the redundant skin can help
the surgeon to achieve predictable and aesthetically
pleasing rhinoplasty results.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflict of

interest other than Dr. Guyuron receives royalties from the Rhino-
plasty Book.

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Aesth Plast Surg
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