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

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.

The Role of Autologous Fat Grafting in Rhinoplasty

“…Camouflaging of irregularities of the nasal dorsum, alar contour, and osteotomies lines: While the efficacy of reliably augmenting the nasal dorsum with fat grafting is still under debate, it seems there is general consensus on the value of fat grafting in camouflaging of dorsal irregularities, especially in thin-skinned patients and in reconstructive or revision cases that involve a scarred SSTE 28,29,56,[60][61][62][63][64][65][66] . Toriumi introduced the Microfat-infused soft tissue (MISTA) method to address the absence of soft tissue space that can be injected with autologous fat.…”

“…It lacks the flexibility to redrape on the osseocartilaginous framework and the mobility while performing the dissection. Moreover, it is usually less vascularized, making the perfusion to support retention of other structural grafts such as cartilage or fascia more difficult 28,[33][34][35] . The regenerative effect of the fat grafts on the surrounding tissues makes it an ideal graft to improve the quality and soften the scarred SSTE 62,[64][65][66][67] .…”

“…These safety measures should be practiced in every case regardless of if the patient underwent the previous rhinoplasty or not. In the case of fat injection after a rhinoplasty, one must also appreciate that the surgically altered architecture of the nasal perfusion network and scarred SSTE may pose even higher risk 28,29,37,38,40 . In our opinion, the most crucial is to manage patients' expectations and assess carefully if they will profit from the fat injection.…”

“…The scarring of the nasal SSTE is known as the "shrinkwrap contracture phenomenon," and it can happen even years after the primary surgery. 28,[33][34][35] This deformational scar formation is prevalent in revision cases. The resultant change in nasal shape is a major reason structural avascular cartilaginous grafts are more likely to be used in secondary rhinoplasty.…”

“…The nasal cartilaginous framework meets its metabolic needs mainly through diffusion from the covering SSTE and the nasal lining mucosa. This unique metabolic characteristic emphasizes the importance of an intact, well-vascularized nasal SSTE to assure adequate perfusion for the nasal cartilaginous framework [28][29][30][31] .…”