Optimizing Outcomes in Thick-Skinned Rhinoplasty: Surgical Maneuvers and Perioperative Medical Management-A Narrative...

Managing the dense nasal soft tissue envelope (STE) remains a formidable challenge in facial plastic surgery. This narrative review aims to evaluate the anatomical challenges associated with thick-skinned rhinoplasty, review intraoperative structural maneuvers, and assess the efficacy of perioperative medical interventions-specifically isotretinoin. A comprehensive literature search was conducted utilizing PubMed/Medline, Scopus, Web of Science, and Embase, yielding literature on anatomical variations, surgical techniques, and medical management. Thick nasal skin is inherently inelastic, predisposing patients to prolonged postoperative edema, increased dead space, and the masking of underlying cartilaginous definition. The reviewed literature suggests that intraoperative strategies relying heavily on robust structural grafting (e.g., columellar struts and septal extension grafts) demonstrate superior long-term projection compared to aggressive soft-tissue defatting alone, which carries risks of vascular compromise. Furthermore, the integration of preoperative skin conditioning and postoperative oral or topical isotretinoin appears to be a promising adjunct to diminish sebaceous gland activity and accelerate edema resolution. However, conclusions regarding isotretinoin must be moderated, as current studies are limited by small sample sizes, heterogeneous methodologies, and a lack of validated patient-reported outcome measures (e.g., FACE-Q). Achieving optimal results in thick-skinned rhinoplasty requires a multimodal approach. The synergistic combination of rigid intraoperative cartilaginous support, careful dead-space management, and judicious, patient-specific medical therapies may help mitigate postoperative fibrosis and improve aesthetic outcomes.