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Rhinoplasty Thin Skin

tatler magazine 2013

Tatler Magazine (2013) - Top Rhinoplasty Surgeon in NYC/New York

Thin skin can be just as problematic as thick skin and requires special techniques to achieve an excellent outcome. Also the nasal skin becomes thinner with each successive nose surgery and a candidate for revision rhinoplasty will have a thinner soft tissue envelope than before the primary nose surgery.

Thin skin usually exists in patients descended from northern European countries. The treatment of either a bump or an enlarged tip cartilage in thin skinned patients is two-fold:

1. Smooth edges have to be created on the nasal bridge and tip at the end of the nose surgery as every little imperfection will become visible when the swelling fades away.
2. Placing soft tissue to thicken the skin on the tip or nasal bridge to camouflage minor irregularities. Dr. Rizk uses either temporalis fascia (soft tissue obtained from the patient's own tissue above their ear) or Alloderm, a safe and readily available collagen sheet, obtained from cadavers and processed with safe FDA approved methods.

Ethnic nose surgery

Top New York Facial Plastic Surgeon Dr. Rizk prefers temporalis fascia since Alloderm does absorb to some extent, although Dr. Rizk has had excellent success with both. Alloderm has been used as a skin replacement for over 20 years for burn patients and has been used extensively in reconstructive and cosmetic plastic surgery.

How do Dr. Rizk’s techniques address the challenges of thin skin?

Dr. Rizk has developed 2 approaches which achieve a smoother and more precise result with rhino plasty. First, Dr. Rizk pioneered the use of the 3d high definition telescopes/cameras to visualize the bump and nasal bridge better during the procedure in order to better sculpt or remove the bump, resulting in smoother edges. Traditional cosmetic surgery involves looking at the bump at a distance from the outside only with the surgeon's eyes without magnification. Dr. Rizk's approach involves seeing the bridge or bump with specialized 3d cameras and telescopes magnified from the inside in addition to the traditional approach. This allows a more precise sculpting of the bridge. (see Media/Publications for published articles by Dr. Rizk on this topic).

Secondly, Dr. Rizk pioneered the use of specialized cartilage and graft sculpting with powered sanding or filing instruments, achieving a smoother result than trimming or sculpting grafts with a regular surgical knife. The traditional knife creates angled edges instead of round edges.

Lastly, Dr. Rizk does not divide the tip cartilage, so- called "lower lateral cartilage" which forms the structure of the nasal tip. (A technique called vertical dome division). Dr. Rizk believes this vertical dome division done frequently in the past should never be used in thin skin patients as it results in visible cartilage edges with time. Instead, Dr. Rizk feels the tip cartilages should have an "intact rim strip" meaning they can be trimmed and sculpted without being completely divided. Many of Dr. Rizk’s patients with thin skin presenting for revision surgery have had a vertical dome division procedure in the past which has resulted in sharp, unnatural edges.

If I already had a rhinoplasty and because of my thin skin have many irregularities, what do I do?

You may be a candidate for revision rhinoplasty to smooth out the edges that are visible and place some soft tissue between the thin skin and the cartilage and bone framework of the nose to give a softer look. Dr. Rizk uses either temporalis fascia (soft tissue from around the patient's ear and area above the ear) or Alloderm. Dr. Rizk recommends waiting a period of 1 year prior to seeking a revision surgical procedure for the swelling to dissipate fully.

What are the advantages and disadvantages between Alloderm and Temporalis fascia in nose surgery to thicken the skin?

Temporalis fascia is the patient's own tissue so infection is less likely to occur but it does involve a second surgical site above the patient's ear to obtain this soft tissue. It rarely absorbs and usually the surgical donor site above the ear heals very quickly.

Alloderm is a collagen sheet processed through FDA approved methods and has been used for many years with a very low infection rate. It can absorb to some extent depending on the patient. It is readily available and eliminates the need for a second surgical site.

What are the risks of revision rhinoplasty in thin skin patients?

Any revision procedure has risks such as scarring, asymmetries, infection, bleeding, although these are not frequent, all risks need to be discussed with patients seeking revision rhinoplasty. Dr. Rizk performs revision surgery only if he feels the benefits to the patient outweigh the risks. Sometimes, Dr. Rizk will not choose to perform the revision if he feels the deformity is minor and the risk is high. Dr. Rizk's practice focuses on the nose and is comprised of 50 percent revision nose procedure.

New York City based Facial Plastic Surgeon Dr. Rizk feels honesty is the most important quality a physician should have and if the patient's requests are not reasonable or if  the revision will achieve limited benefit, this should be disclosed to the patient.