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THE THICK-SKINNED TIP AND RHINOPHYMA
Thick nasal tip skin can be a problem in the man that worsens with age as the glandular component of the skin increases. The previous cartilage techniques alter the structure but not the skin itself. Simple debulking of the underlying tip soft tissue may be helpful, especially via an external approach, but must be done conservatively so as not to disrupt the blood supply to the tip skin and create tissue loss. Debulking does not change the glandular component in these cases, tip grafts are utilized to provide a sharper structure underneath the overlying thick-tissue envelope, which will hopefully lead to increased definition (Fig. 21).
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Fig. 21. Tip grafting using the open rhinoplasty approach. A, To avoid unnatural sharpness in the tip postoperatively, cartilage grafts should be carved to bevel all the surfaces. Anteriorly, the graft should be notched centrally to mimic the natural tip-defining points. The graft is tapered posteriorly to more naturally accommodate the width of the columella, so as not to impinge upon the nasal soft-tissue facets. B, In preparation for graft placement, irregularities along the inferior margin of the medial crura should be trimmed to smooth surface. C, When additional support is required for the nasal tip, a medial crural strut is placed that extends from the premaxillary space to a point just below the domes. D, The graft is positioned below the inferior surface of the medial crura. Several interrupted sutures are required to adequately fix the graft along the margins of the medial crura and alar domes. E, The final graft placement demonstrates projection of its anterior margin beyond the existing alar domes. The graft can be placed in a position of slight overprojection before stabilizing it with sutures. After the graft is firmly secured in position, the anterior margins can be precisely sculpted to the optimal degree of projection required. If the graft has been placed in a position of inadequate projection, it should be removed and repositioned further anteriorly. (From Kridel RWH, Konior RJ: The underprojected tip. In Krause C, Mangat D, Pastorek N (eds): Aesthetic Facial Surgery. Philadelphia, JB Lippincott, 1991, pp 191-228; with permission.) |
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No traditional rhinoplasty surgery, however, effectively treats the excessively glandular tip or the patient with rhinophyma or rosacea (Fig. 22). Treatment for these patients begins conservatively with topical applications of alpha hydroxy acids and prescriptions for such medications as Metrogel (metronidazole) and isotretinoin. Skin resurfacing options include chemical peeling, laser resurfacing, and actual curettage, depending on the severity of disease.
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Fig. 22. A, C, and E, This 64-year-old man presented with a boxy, bifid, bulbous nasal tip with thick glandular nasal tip tissue and a dorsal hump. B, D, and F Postoperative photographs reflect the use of a columellar strut, a tip graft, a double-dome technique, and a debulking of the supratip skin from the undersurface, via an external rhinoplasty approach. The results show a decided improvement in the shape of the nose, but the nasal tip skin itself is still thick. Illustration continued on following page |
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