Case Report

Rhinoplasty in Thick Skinned Patients, is there a Role for the Dermatologist?

Amani A Obeid*

Department of Otolaryngology-Head and Neck Surgery, King Saud University, Riyadh, Saudi Arabia

Submission: November 13, 2019; Published: November 20, 2019

*Corresponding author: Amani A Obeid, Division of Facial Plastic Surgery, Department of Otolaryngology-Head and Neck Surgery, King Saud University, Riyadh, Saudi Arabia

How to cite this article: Amani A Obeid. Rhinoplasty in Thick Skinned Patients, is there a Role for the Dermatologist?. JOJ Dermatol & Cosmet. 2019; 2(1): 555579.

Abstract

Rhinoplasty in thick Skinned patients can be very challenging. This is of great importance for surgeons whom practice involves patients from the Middle east, South America, Africa and Asia as a good percentage of the population has thick skin. In dealing with nasal surgery for patients with thick skin, many challenges arise; the relatively inelastic skin-soft tissue envelope, small weak nasal cartilages leading to weak structural support, the tendency for scar formation and prolonged post-operative edema are all culprits to less than ideal results. In this review, I would like to highlight the importance of proper skin management in dealing with such cases. This includes pre-operative skin preparation and post-operative care.

Keywords: Rhinoplasty; Thick Skinned; Skin-soft; Epidermis; Surface Oiliness; Exfoliation; Ingredients; Skin Inflammation

Introduction

Pre-Operative Skin Preparation

All Patients benefit from a perioperative skin care program. However, this is crucial in thick skinned patients. The main objectives are to re-establish healthy skin conditions (as much as possible) and to diminish the skin’s inflammatory response [1,2]. This can be achieved by addressing all skin layer; epidermis, dermis and subcutaneous tissue. Regarding epidermal layer, products that control surface oiliness, promote exfoliation, unclog pores, and decrease trapped sebum can be used. A simple daily regimen can be developed and tailored to each individual patient need, preferably in collaboration with a dermatologist. Suggested products include:

a. A cleanser: According to patient skin type, a gentle cleanser or one that include active ingredients can be used. These include gentle exfoliants to unclog pores such as glycolic acid or salicylic acid and topical antibacterial such as benzoyl peroxide to control skin inflammation [3-5].

b. Topical retinoids: Topical retinoids have been shown to modulate epidermal keratinization and differentiation and alter various transcription factors involved in cascades of skin inflammation [6].

c. Sunblock and minimizing sun exposure in order to stabilize the epidermis against UV light injury [4].

d. Additional treatments: These include moisturizers topicalantioxidant, topical antibiotics, micro dermabrasion, and in-office peels, depending on individual skin issues [7-9].

To achieve best results, a skin care regimen should be started 4-6 weeks before surgery. If this is not possible, they can be started at the initial consultation and followed until the patient is operated upon. To avoid hypersensitivity reactions from topical disinfectants and adhesive materials placed over the nose during surgery, products containing active ingredients should be stopped stop 5 days before surgery, to be resumed 10 days afterwards [2]. Regarding deeper skin layers, the rational of topical and systemic treatments is to control sebum production, this will diminish size of sebaceous glands and will eventually decrease inflammation and swelling. This can be achieved predominantly by topical or oral retinoids [6,10]. Adjuvant therapeutic modalities include trichloroacetic acid TCA peels, photodynamic therapy, and intradermal botulinum toxin [11-13]. It is important to highlight that in severe cases where oral isotretinoin is used, no evidence supports delaying skin surgery. It can be stopped one week before surgery and restarted 2 to 3 weeks after surgery. If the patient wants surgery first, it can be started two weeks after surgery [2,14,15].

Post-Operative Care

The rationale behind post-operative care is to decrease edema, minimize inflammation, and eliminate dead space. Simple measures such as head elevation, cold compresses, avoiding excessive sun exposure and strenuous exercise shouldn’t be overlooked

a. Medications such as non-steroidal anti-inflammatory drugs can be used to control both pain and soft tissue swelling, oral antihistamines and nasal steroids for allergic rhinitis control, and judicious use of oral steroid can greatly reduce the extent and duration of post-operative edema [16,17].

b. In regard to the above-mentioned skin care regimes, they should be followed postoperatively for at least 6-12 months after surgery to achieve best results.

c. Taping: in patients with thick nasal skin, postoperative taping is essential. It helps to compress the skin envelope to the underlying framework, therefore eliminating dead space. The effects of nasal taping have been demonstrated recently by Ozucer et al. who showed that 4 weeks of post-rhinoplasty taping significantly decreased postoperative edema in the thick skin patient population. It is recommended to use hypoallergenic porous tape to minimize skin reaction from taping [18].

d. Massage: Many surgeons advise thick skin patients to perform nasal massage three times a day for several months after tapes are removed. The patient should stand in front of a mirror and place extended index fingers on each side of the lateral nasal sidewall. Skin should be stretched, and fingers should exert pressure on the bones pushing everything slightly to the midline. This will help eliminate edema and dead space formation. Despite the popularity of this practice by many surgeons, compelling evidence is currently lacking to support this practice.

e. Injectable steroids and 5-Flurouracil: If supra-tip fullness develop postoperatively, different protocols are proposed; 0.1- 0.2 ml of triamcinolone 10-40 mg/ml can be administered every 4-6 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 [19-21]. In resistant cases, 5-fluorouracil, hyaluronidase or a combination of these agents can be used [22,23].

Conclusion

In conclusion, dealing with thick skin patients undergoing rhinoplasty can be a daunting task. It is important for both the surgeon and the patient to understand the importance of pre and post-operative skin care as its contribution to a satisfactory result is as important as the surgical technique. The importance of having experienced dermatologist on board couldn’t be overemphasized.

References

1. Kosins AM, Obagi ZE (2017) Managing the difficult soft tissue envelope in facial and rhinoplasty surgery. Aesthetic surgery journal 37(2): 143-157.
2. Cobo R, Camacho JG, Orrego J (2018) Integrated management of the thick-skinned rhinoplasty patient. Facial Plastic Surgery 34(01): 3-8.
3. Briden M, Green B, Gostomski J, Edison B (2015) Minimally invasive free acid glycolic acid peels improve a wide range of inflammatory, pigmentary and aging skin conditions. Journal of the American Academy of Dermatology 72(5).
4. Kim MR, Kerrouche N (2018) Combination of benzoyl peroxide 5% gel with liquid cleanser and moisturizer SPF 30 in acne treatment results in high levels of subject satisfaction, good adherence and favorable tolerability. Journal of Dermatological Treatment 29(1): 49-54.
5. Del Rosso JQ (2013) The role of skin care as an integral component in the management of acne vulgaris: part 1: the importance of cleanser and moisturizer ingredients, design, and product selection. The Journal of clinical and aesthetic dermatology 6(12): 19-27.
6. Wolf JE (2002) Potential anti-inflammatory effects of topical retinoids and retinoid analogues. Advances in therapy 19(3): 109-118.
7. Vestergaard M, Ingmer H (2019) Antibacterial and antifungal properties of resveratrol. International journal of antimicrobial agents 53(6): 716-723.
8. Toyoda M, Morohashi M (1998) An overview of topical antibiotics for acne treatment. Dermatology 196(1): 130-134.
9. Kim SW, Moon SE, Kim JA, Eun HC (1999) Glycolic Acid versus Jessner’s Solution: Which Is Better for Facial Acne Patients? A Randomized Prospective Clinical Trial of Split‐Face Model Therapy. Dermatologic surgery 25(4): 270-273.
10. Çölgeçen E, Özyurt K, Kesikoğlu Af (2016) The effect of systemic isotretinoin treatment on skin biophysical parameters among patients with acne vulgaris. Turkish journal of medical sciences 46(6): 1641-1644.
11. Kim RH, Armstrong AW (2011) Current state of acne treatment: highlighting lasers, photodynamic therapy, and chemical peels. Dermatology online journal 17(3): 2.
12. Shuo L, Ting Y, KeLun W, Rui Z, Rui Z, et al. (2019) Efficacy and possible mechanisms of botulinum toxin treatment of oily skin. Journal of cosmetic dermatology 18(2): 451-457.
13. Wiegell SR, Wulf HC (2006) Photodynamic therapy of acne vulgaris using 5-aminolevulinic acid versus methyl aminolevulinate. Journal of the American Academy of Dermatology 54(4): 647-651.
14. Ungarelli LF, Hetem CMC, Junior JAF (2016) Is it safe to operate on patients taking isotretinoin? Aesthetic plastic surgery 40(1): 139-148.
15. Spring LK, Krakowski AC, Alam M, Bhatia A, Brauer J, et al. (2017) Isotretinoin and timing of procedural interventions: a systematic review with consensus recommendations. JAMA dermatology 153(8): 802-809.
16. Hoffmann DF, Cook TA, Quatela VC, Wang TD, Brownrigg PJ, et al. (1991) Steroids and rhinoplasty: a double-blind study. Archives of Otolaryngology–Head & Neck Surgery 117(9): 990-993.
17. Hwang SH, Lee JH, Kim BG, Kim SW, Kang JM (2015) The efficacy of steroids for edema and ecchymosis after Rhinoplasty: A meta‐analysis. The Laryngoscope 125(1): 92-98.
18. Ozucer B, Yıldırım YS, Veyseller B, Tugrul S, Eren SB, et al. (2016) Effect of postrhinoplasty taping on postoperative edema and nasal draping: a randomized clinical trial. JAMA facial plastic surgery 18(3): 157-163.
19. Hussein WK, Foda HM (2016) Pollybeak deformity in middle eastern rhinoplasty: prevention and treatment. Facial Plastic Surgery 32(4): 398-401.
20. Hanasono MM, Kridel RW, Pastorek NJ, Glasgold MJ, Koch RJ (2002) Correction of the soft tissue pollybeak using triamcinolone injection. Archives of facial plastic surgery 4(1): 26-30.
21. Guyuron B, DeLuca L, Lash R (2000) Supratip deformity: a closer look. Plastic and reconstructive surgery 105(3): 1140-1151.
22. Irvine LE, Nassif PS (2018) Use of 5-Fluorouracil for Management of the Thick-Skinned Nose. Facial Plastic Surgery 34(1): 9-13.
23. Blugerman G, Schavelzon D, Wexler G (2016) Five Fluorouracil, Hyaluronidase and Triamcinolone in the Nasal Region. Miniinvasive Techniques in Rhinoplasty: 113.