Refinement of Thick Nasal Skin Using Bilevel Dissection and Subcutaneous Reduction

Biplane Skin Dissection and Subdermal Tissue Reduction in Thick Nasal Skin

I wanted to share a video with you about bilevel skin dissection (or biplane dissection and underskin tissue removal), a technique used to thin the skin during rhinoplasty in patients with thick, round, and porous nasal skin.

Caution: Contains bloody images and may be disturbing for some patients!

Bilevel skin dissection (or biplane dissection) is a specialized technique used in rhinoplasty for thick skin to thin the heavy soft tissue covering that often hides the underlying cartilage, thereby increasing the visibility of the underlying cartilage. This technique is commonly used to address specific cosmetic concerns, such as in certain ethnic types, patients with oily and round, wide nasal tips, or those with African-descended noses.

It's important to state from the outset that skin structure is a genetic characteristic and that this method alone cannot permanently prevent the regeneration of fibroadipose tissue under the skin. In short, this method is an auxiliary skin thinning technique in rhinoplasty for thick skin.

Advanced Skin Thinning Techniques in Thick-Skinned Rhinoplasty: Biplane Dissection Approach - Why is it Performed?

Purpose and Benefits: In patients with thick skin, the skin is heavy and less elastic, often unable to properly adapt to the new, smaller skeleton. This can result in a rounded, thick, and coarse appearance on the outside of the nose, roughly like a thin and frail person wearing a thick snowcoat, which can lead to a "polly beak" deformity (a round, soft tissue lump) after surgery. When the thick skin structure is understood before surgery, patients should definitely be informed about techniques such as biplane skin dissection and subcutaneous reduction, and it should be explained that the simulation may differ from the actual surgical outcome.

Other Different Applications in Thick Skin Rhinoplasty

In patients with thick skin and subcutaneous tissue, besides two-plane subcutaneous dissection and underxin tissue removal, it is important to avoid leaving dead space under the skin (as genetic thick skin can lead to fibroadipose tissue production), to preserve the cartilage support structure as much as possible, and to be careful in placing cartilage grafts (a heavy nasal tip that easily droops downwards can make patients unhappy, and at the same time, it is beneficial to minimize dead space as much as possible with cartilage grafts).

The Benefits of This Approach Are: Optimizing Thick Skin Rhinoplasty with Bilevel Dissection and Tissue Debulking

Reducing Skin Thickness

Thick skin in the nose is genetic, and it's not possible to prevent the production of soft tissue under the skin with just a surgical procedure. However, bilevel skin dissection and tissue debulking help reduce skin thickness.

Improved Coverage

It helps the skin to better conform to the cartilage structure of the nasal tip that is reshaped during rhinoplasty surgery.

Reducing the "Camouflage Effect"

Thick skin characteristics "thickly wrap" the underlying cartilage grafts, making it impossible for features such as an "angular nose," a "double-reflecting nasal tip," or a "small and thin nasal tip" to appear as patients expect. Bilevel dissection and subcutaneous reduction reduce the excess tissue that conceals the structural improvements made to the nasal tip.

Surgical Technique of Bilevel Skin Dissection (or Biplane Dissection) and Underskin Tissue Removal For Skin Thinning

Rhinoplasty is a personalized surgery, and you may need to discuss the necessity of this procedure with your doctor before the operation. This surgical skin thinning procedure should be performed using an "open technique rhinoplasty." Performing bilevel skin dissection with a closed technique is very difficult. In patients with thick skin and a bulbous nasal tip, open technique rhinoplasty and bilevel skin dissection are preferred. The procedure begins with a classic columellar incision, followed by dissection and upward lifting of the skin. Generally, two different techniques can be used: thick dissection of the skin or thin dissection. I usually elevate the skin by thinly dissecting it. I separate the underlying fibroadipose tissue from the cartilage framework and remove it. However, some surgeons also perform the procedure by elevating the skin thickly and then shaving the subcutaneous tissue with scissors. 

This removed tissue can also be used for augmentation of the nasal bridge or filling in the nasal root. Here's the links I previously shared about this >> Combination Three Different Applications For Rhinoplasty Without Breaking Bone / We Performed Nose Tip Lifting + Nose Root Filling Without Hump Reduction and Bone Touching

How to Detect Very Thick Skin and Thick Skin Characteristics in Patients?

How can we tell if someone's nasal skin is thick? There are two very easy methods for this.

The first method is to look closely at the tip of the nose; if there are many comedones and it has a round and fleshy appearance, this means the nasal tip has "very thick skin."

The second method is during examination; if you gently squeeze the skin and subcutaneous tissue with your index finger and thumb from top to bottom and notice a significant difference in thickness at the nasal tip, this means the nasal tip has "very thick skin." It is often noticed that patients with very thick noses have mothers or fathers with similar nasal characteristics.

Risks and Complications of Bilevel Skin Dissection (or Biplane Dissection) and Underskin Tissue Removal 

It is important to avoid excessive thinning of the skin and asymmetrical dissection during this surgical procedure. In patients who have previously undergone rhinoplasty, subcutaneous scar and suture reactions can make dissection very difficult and increase the risk of circulatory problems. Patients may be informed that there is a risk of the body producing similar tissue again during the healing period and that they should wait 12-18 months for the final results. It is important for patients to pay attention to postoperative care recommendations.

If too much subcutaneous tissue is removed, skin depressions or irregularities may occur after the procedure.

Post-Operative Care Recommendations

The following post-operative care recommendations are important after a rhinoplasty with thick skin and bilevel skin dissection:

Apart from these surgical procedures, patients with thick skin may also use Isotretinoin Capsules after surgery. I previously published the following link regarding the use of (Roaccutane/Zoretanin): Use of Isotretinoin Capsules (Roaccutane / Zoretanin) Before and After Rhinoplasty. I also published this link for steroid injections after rhinoplasty for patients with thick and edematous skin: Steroid Injection After Rhinoplasty

Postoperative care recommendations for these patients include applying pressure to the nose with a sling (nasal sling techniques and applying pressure to the nose with an aluminum cast can reduce dead space under the skin and reduce unnecessary fibroadipose tissue production).

Patients may be advised to restrict salt in their diet for up to 6 months. Classic recommendations such as using bromelain tablets and arnica gel can be applied for a longer period.

To read other articles on bilevel skin dissection by Dr. Murat Enoz published on this site, you can click on the search result link (you can access other articles by clicking on "other articles" at the bottom of the opened link) >> https://www.ent-istanbul.com/search?q=bilevel+skin+dissection

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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