title: Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery.
abstract: BACKGROUND
  The nasal soft tissue envelope affects the final rhinoplasty result, and can limit the expected improvement. Currently, no dependable and objective test exists to measure the thickness of the nasal skin and underlying soft tissue.
  
  
  OBJECTIVE
  This paper presents a simple, yet reliable method to determine the thickness of the soft tissue envelope. An algorithm is presented for treatment of the dermis and/or soft tissue apart from surgery of the underlying osseocartilaginous structures.
  
  
  METHODS
  Seventy-five patients presenting for primary rhinoplasty underwent visual and ultrasound assessment of their nasal soft tissue envelope. At preoperative evaluation, the Obagi "skin pinch test" was used to assess the thickness of the nasolabial fold and whether or not the skin was oily. Patients were classified based on the pinch thickness. At time of surgery prior to injection of local anesthesia, ultrasonic assessment was done at the nasolabial fold, keystone junction, supratip, and tip to measure the thickness of the nasal dermis and underlying soft tissue.
  
  
  RESULTS
  Patients determined to have thin, normal, and thick skin by the "skin pinch test" were found to have a nasolabial fold dermal thickness with an average of 0.7 mm (0.4-1.2 mm), 1.1 mm (0.8-1.8 mm), and 1.4 mm (0.7-2.0 mm). Patients determined to have thin, normal, and thick skin were found to have a dermal thickness at the keystone junction with an average of 0.3 mm (0.2-0.4 mm), 0.5 mm (0.3-1.1 mm), and 0.9 mm (0.6-1.2 mm), respectively. This difference in thickness also translated to the supratip and tip areas measured. However, all areas were also affected by the oiliness of the skin. Soft tissue thickness (SMAS and muscle) underlying the dermis was variable. Patients of non-Caucasian background were more likely to have a thicker soft tissue layer.
  
  
  CONCLUSIONS
  The "skin pinch test" is an easy and reliable way for the surgeon to evaluate the thickness of the nasal soft tissue envelope. The rhinoplasty surgeon can make decisions pre- and postoperatively to treat patients with difficult soft tissue envelopes. LEVEL OF EVIDENCE 4.
authors.affiliation: Dr Kosins is a Clinical Assistant Professor, University of California, Irvine School of Medicine, Irvine, CA; and Rhinoplasty Section Co-editor for Aesthetic Surgery Journal. Dr Obagi is a dermatologist in private practice in Beverly Hills, CA.
authors.forename: Aaron M
authors.initials: AM
authors.lastname: Kosins
authors.affiliation: Dr Kosins is a Clinical Assistant Professor, University of California, Irvine School of Medicine, Irvine, CA; and Rhinoplasty Section Co-editor for Aesthetic Surgery Journal. Dr Obagi is a dermatologist in private practice in Beverly Hills, CA.
authors.forename: Zein E
authors.initials: ZE
authors.lastname: Obagi
mesh_terms: D000328:Adult; D000465:Algorithms; D059925:Anatomic Landmarks; D003661:Decision Support Techniques; D004954:Esthetics; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000033:anatomy & histology / Q000601:surgery; D060052:Nasolabial Fold / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000601:surgery*; D009666:Nose / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000601:surgery*; D010781:Photography; D010808:Physical Examination; D011237:Predictive Value of Tests; D044469:Racial Groups; D015203:Reproducibility of Results; D012225:Rhinoplasty / Q000009:adverse effects / Q000379:methods*; D012867:Skin / Q000033:anatomy & histology* / Q000000981:diagnostic imaging; D040521:Subcutaneous Tissue / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome; D014463:Ultrasonography; D014796:Visual Perception; D055815:Young Adult