Thin Skin Rhinoplasty: Aesthetic Considerations and Surgical Approach

Thin nasal skin readily reveals imperfections of the underlying osseocartilaginous framework and has profound implications for the surgical planning and execution of rhinoplasty. Thin skin may be a normal variant or the result of prior surgery, trauma, or disease. The relative inattention to this subject in the literature is striking, particularly when one considers the small tolerance for error that exists when working with thin skin. One possible explanation is the misconception that relatively few techniques are available to improve surgical results in this difficult group. Another explanation for this conspicuous omission is the prevailing notion that the character of thin skin is largely immutable. This chapter addresses these concerns and introduces a variety of techniques that we have found beneficial in patients with thin nasal skin.

In this discussion, “thin skin” and “thin nasal skin” more properly refer to a thin nasal skin–soft tissue envelope (SSTE). When anatomic reference to the skin of the nose in isolation is intended, we refer specifically to the epidermis, dermis, or cutaneous layer. We have chosen this potentially confusing terminology because most clinicians tacitly include the four layers of tissue between the skin and osseocartilaginous framework when they speak of patients with thin skin. Furthermore, this approach allows us to consider in our discussion of thin skin both patients with naturally fine skin as well as patients who have undergone prior rhinoplasty and have thin SSTEs with a parchment-like character. Several of the technical considerations in these two groups are similar. The aging nose, discussed in a separate chapter, also exhibits thinning of the SSTE and is briefly addressed in this discussion.

Anatomy of the Skin-Soft Tissue Envelope

The anatomy of the SSTE and its relation to the nasal framework is of great interest to the rhinoplasty surgeon working with thin nasal skin. The thickness of the SSTE varies, being thickest over the radix and supratip area and thinnest at the rhinion. There are four layers of tissue that reside between the skin and osseocartilaginous framework: the superficial fatty panniculus, the fibromuscular layer, the deep fatty layer, and the perichondrium or periosteum. The fibromuscular layer contains the nasal superficial musculoaponeurotic system (SMAS), which is in continuity with facial SMAS, platysma, and galea. This layer provides structure and is flush to the underlying vascular supply of the SSTE. In the patient with thin nasal skin, extra care is taken to preserve the vascular supply of the SSTE by elevating a flap immediately superficial to the perichondrium.

The facial muscles exert dynamic forces on the nose that are often pronounced in patients with thin skin. The nasal muscles are innervated by the zygomatic branch of the facial nerve and have been divided into four groups: elevator, depressor, compressor, and minor dilator muscles. The elevator muscles, including the procerus, levator labii superioris alaeque nasi, and anomalous nasi, shorten the nose and dilate the nostrils. The depressor muscles, including the depressor septi and alar portion of the nasalis, lengthen the nose and dilate the nostrils. The compressor muscles, including the transverse portion of the nasalis and compressor narium minor, lengthen the nose and contract the nostrils. Last, the minor dilator muscle is the dilator naris anterior. These muscles have functional and aesthetic relevance to thin skin rhinoplasty, with their role in surgical treatment sometimes described as “dynamic rhinoplasty.” Understanding these muscle actions allows for improved control of dorsum–tip–labial relationships.

Types of Thin Skin

Naturally Thin Skin

In patients who have not undergone prior nasal surgery, the thickness of the supratip soft tissue is dictated by the density of sebaceous glands in the epithelium and the suppleness of the subcutaneous tissues. Patients with “thick skin,” discussed in detail in Chapter 27 in the text, usually have sebaceous skin with dense underlying soft tissues that obscure nasal framework and resist surgical refinement. Patients with naturally fine skin have the opposite problem—skin that reveals too much—and subtle imperfections will “shine through” the delicate veil of the thin nasal covering. In such cases, absence of the usual buffer of skin and soft tissue will often draw attention to the contours of the underlying cartilaginous and bony nasal anatomy in an unflattering manner. Thin skin may occur irrespective of age, gender, or ethnicity; however, the prototypical thin-skinned patient in the senior author's practice is a young woman in her 30s, often of Nordic descent, with fair skin, blonde or red hair, and blue eyes (Fitzpatrick Type I or II).

Parchment Thin Skin

Thin skin is also seen in association with prior rhinoplasty. The prototypical patient in this setting is a female with medium to medium-thin facial skin who relates a history of progressive changes to the character of the skin subsequent to one or more prior rhinoplasties. Examination of the skin and its underlying soft tissue elements demonstrates atrophic changes in association with scarring. Actinic changes or talangiectasias are usually present, often over the rhinion, and there is poor elasticity to the nasal covering. This skin is sometimes described as “parchment thin skin,” a reflection of its fragile quality and its thin, almost translucent appearance.

In the previously operated nose, thin skin may be adherent to the underlying framework. As a result, the underlying cartilaginous and skeletal irregularities stand out in relief. Parchment preparation, which historically involved the stretching, scraping, and drying of skin under tension to create a stiff, translucent material, has much in common with the pathogenesis of iatrogenic thin skin in postrhinoplasty patients. Thinness of the SSTE—often unrecognized at time of original surgery—predisposes to development of this complication, but parchment thin skin usually indicates transection or injury of the nasal SMAS during dissection. This transgression permanently compromises skin quality and increases risk of alar retraction due to exaggerated scarification. Steroid injection compounds the problem.

Aging and Disease-Related Thin Skin

Last, normal aging and several disease entities cause thinning of the skin. These causes have an underlying physiology that differs from both innately thin nasal skin and from acquired parchment thin skin. Aging is associated with reduction of the skin's strength, thickness, and elasticity. Actinic changes and solar damage also alter the characteristics of the skin and contribute to thinning and premature aging of the skin. Corticosteroid excess, as may occur with diseases of the adrenal cortex, pituitary neoplasms, and exogenous corticosteroid use are additional factors associated with thinning, weakening, and delayed healing of the skin. Ehlers-Danlos syndrome and osteogenesis imperfecta, which are associated with defective collagen synthesis, result in abnormally thin skin with decreased tensile strength, as part of their clinical behavior. While the techniques presented herein for thin skin are highly versatile, the dynamics of healing in aging and disease are beyond the scope of this chapter.

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