Commentary on: Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery

Skin: the final frontier for rhinoplasty. The experimental discoveries of the authors in “Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery” provide a voyage for our viewers into the next quantum leap for rhinoplasty.1 Their mission has been to seek a new path, and a new algorithm for preventing and treating the amorphous thick skinned nasal tip. Their exploration with ultrasonography has enabled them to go boldly where most surgeons (using anatomic framework reconstruction alone) have not been able to go before. For several decades the focus of our collective attention (as rhinoplasty surgeons) has been on the cartilage and bone in order to control the final outcome, both aesthetically and functionally. With the advent of grafting and suture techniques, that aspect of rhinoplasty control has been largely achieved and brought better postoperative results to our patients than ever before. The skin, unfortunately, has always and continues to be a dilemma in many patients because, quite obviously, thick skin and subcutaneous fat blunt even the most exquisite framework results. Although some have argued that the skin is not merely a cover (drape) over the anatomic framework2 and that a good result is not mostly dependent upon the resultant bony/cartilaginous framework, most surgeons have adopted the surgical drape philosophy, we included. Thus, if for some reason the surgical result was not entirely satisfactory, there would always be an opportunity to return to the operating room at the appropriate time and revise the framework. However, the assumption and hope has been that the skin and subcutaneous tissue will cooperate by being pliable and not deposit too much subcutaneous scar to blunt the sculpted result. Unfortunately, reliance on the skin to cooperative has been frequently disappointing. The authors provide practical solutions by providing an article that is succinct …