Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery

Overview

Skin thickness limits what rhinoplasty can show, but there was no reliable way to measure it. Kosins and Obagi assessed 75 patients with the Obagi pinch test (thickness and oiliness of the nasolabial fold) before surgery, then measured dermal and soft-tissue thickness by ultrasound at the nasolabial fold, keystone, supratip and tip at the start of surgery.

Sections of note

• Nasolabial fold dermal thickness: thin 0.7 mm (0.4-1.2), normal 1.1 mm (0.8-1.8), thick 1.4 mm (0.7-2.0).
• Keystone dermal thickness: thin 0.3 mm (0.2-0.4), normal 0.5 mm (0.3-1.1), thick 0.9 mm (0.6-1.2).
• The same pattern held at the supratip and tip; oiliness affected all areas.
• Soft tissue beneath the dermis (SMAS and muscle) was variable; non-Caucasian patients were more likely to have a thicker layer.
• An algorithm is presented for treating the skin separately from the framework. Level of Evidence 4.

What it means for a patient

• Thick or oily nasal skin will blur the definition surgery creates; the pinch test is a quick way for the surgeon to classify it.
• Skin can be treated (for example with retinoids or isotretinoin) before or after surgery, separately from the bone and cartilage work.
• The test is validated against ultrasound in this study, not against surgical outcomes.

Why this paper matters

It gives surgeons a bedside test correlated with objective measurement for the most under-discussed determinant of results. Limits: 75 patients, single practice, no outcome data.

Terms

• Soft-tissue envelope: the skin and layers beneath it over the nasal skeleton.
• Dermis: the thick inner layer of skin.
• SMAS: the fibromuscular layer between skin and cartilage.
• Nasolabial fold: the crease from nose to mouth corner.
• Keystone junction: where the nasal bones meet the cartilage on the bridge.