In rhinoplasty, surgeons modify the osseocartilaginous framework (OCF) to achieve optimal aesthetical and functional results. Patients with pre-existing skin conditions such as inherent thick sebaceous skin, acne, or rosacea require the input of dermatologists to ensure the nasal skin-soft tissue envelope (SSTE) remains intact for the best post-operative outcomes. Following is a review, published in the International Journal of Dermatology, of the most significant pre- and post-surgical assessments surgeons and dermatologists should perform in this patient population.
Preoperative Evaluation of SSTE
- Classify the nasal skin as either thick, moderate, or thin. Although computed tomography, magnetic resonance imaging, and ultrasound are objective methods available to assess the nasal skin, standard of care is for the surgeon to rely on the clinical exam.
- Classification of the nasal skin is crucial for surgical planning.
- Subtle irregularities in the OCF may become more visible in thin-skinned patients, while well-defined nasal defining points are more difficult to achieve in thick-skinned patients, leading to an amorphous nose.
- Avoid irregularities of the OCF during surgery, as any minor edges would be palpable or visible after surgery in thin-skinned patients, affecting the aesthetic results.
- Manage thick skin in a surgical-medical manner. For example, in patients with thickened dermis due to sebaceous gland hyperplasia, diminishing the sebaceous glands’ activity preoperatively prevents hyperplasia and leads to thinner skin and a more well-defined nose.
- Control sebum production preoperatively. Sebum-rich skin can prevent natural exfoliation and cause local inflammation with hyperperfusion of the face, disrupting normal skin structure. Seborrheic skin also causes dead keratinocyte retention, predisposing it to superinfection.
- Perform a dermatological consult if skin conditions such as seborrhea, porosity, pigmentation disorders, elasticity, sensitivity, and the presence of dermal pathologies such as rosacea, postinflammatory hyperpigmentation (PIH), and acne, are present, as these conditions may worsen after surgery.
- Perform a dermatological consult to ensure a healthy skin status before surgery. A healthy integument is characterized by proper hydration, elasticity, and the absence of skin barrier or texture damage. This can be achieved by properly cleaning and exfoliating the skin and controlling sebum production.
- Mechanical and/or chemical peels enhance exfoliation, control sebum, and unplug pores.
- Topical retinoic acid diminishes pore size and enhances the barrier function of the epidermis.
- Sun blockers help decrease the skin’s sensitivity to UV light and slow photoaging.
- A recent publication recommended preoperative preconditioning of thick-skinned patients with a combination of salicylic acid, mechanical exfoliation, alpha hydroxy acids, and retinoids to diminish the size of sebaceous glands. It was applied to patients for a minimum of 6 weeks preoperatively and stopped 5 days before surgery.
- Low-dose isotretinoin (0.25-0.4 mg/kg/day) can be used off-label with strict monthly monitoring of blood parameters for patients with severe acne, rosacea, or sebaceous thick skin. Isotretinoin should be stopped 1 week before surgery due to possible increased skin vulnerability and impaired wound healing. It can be restarted 2 to 3 weeks post-surgery.
- Postoperative measures control sebum production, edema, inflammation, and scarring regardless of SSTE thickness, although thick-skinned patients are more prone to edema and scarring after rhinoplasty in the nasal tip area leading to an ill-defined amorphous nose.
- Peeling and retinoids should be continued, at earliest, 10 days postoperatively.
- After 5 to 6 months of retinoid treatment, patients can switch to retinol for maintenance therapy.
- Sun protection is extremely important.
- Postoperative use of isotretinoin should be continued every 3 to 4 weeks post-surgery for at least 4 to 5 months. A dose of 20 mg/day has been recommended.
- Isotretinoin 0.5 mg/kg/day has been used off-label after rhinoplasty in thick-skinned patients for a more defined nasal tip and to diminish scarring and local inflammation. Although it showed better cosmetic results and patient satisfaction with short-term follow-up, no significant cosmetic or patient satisfaction results were seen at a 1-year follow-up. Its use for this indication still requires further study.
- Chemical peels with or without Fraxel CO2 laser resurfacing may be helpful for increased porosity and rough skin texture in thick-skinned patients after rhinoplasty. Isotretinoin should only be restarted after complete recovery from laser or chemical skin resurfacing.
Saadoun R, Risse EM, Crisan D, Veit JA. Dermatological assessment of thick-skinned patients before rhinoplasty –what may surgeons ask for? Int J Dermatol. Published online July 3, 2022. doi:10.1111/ijd.16341