Intradermal hyaluronidase: The answer to treatment in softening a fibrous thick supratip skin in rhinoplasty?

@# It is a common goal for rhinoplastic surgeons to make the best-looking tip with proper projection, maintaining the tip lobule appearance with a supratip break. (Figure 1) However, a fibrous thick skin with fullness may not achieve the ideal tip. It is one of the nuisances in rhinoplasty that makes tip definition surgery difficult. The supratip area remains firm and convex causing a wide bulbous feature of the tip. Several techniques have been introduced with good results however some may still result in supratip fullness because of the firm fibrous nature of thick skin.1-3 Hyaluronidase is an enzyme that depolymerizes hyaluronic acid which is present in the epithelium.4 The use of intradermal hyaluronidase for thick skin was discovered by the junior author (JMP) in one of his rhinoplasties when he injected hyaluronidase in a nose with fillers containing hyaluronic acid. The fillers not only instantly dissolved but the skin also softened, so he tried injecting intradermally in his subsequent rhinoplasties on non-filler noses with fibrous thick skin and indeed found the same effect of softening of the fibrous supratip skin. We here describe the technique used in this preliminary clinical series.

Correction of Blunt Nasal Tip with "Contour Tip Gragt" and Alar Cartilage Modification

The aim of aesthetic rhinoplasty is to produce harmonious contour of the nasal tip as well as to provide dorsal augmentation. The nasal tip should look definite but not too pointed or artificial. Natural contour is most desirable. Among the patients(n = 140) who had augmentation rhinoplasty between 1995 to 1999, 107 patients were classified to have blunt tips. The cases who have other types of tip deformities were excluded. In this study, we present our tip plasty technique for the correction of blunt tips. The blunt tip deformities were divided into bulbous tip(n = 82) and broad tip(n = 25). As for the operation, different tip thinning procedures were done according to this classification. Then dorsal augmentation with silastic implant was performed. Authors used "Contour Tip Graft" technique to produce aesthetic oriental nasal tip. This technique made use of the graft of stacked autogenous cartilages with small pieces of diced cartilage around it. The stacked cartilages were for tip projection and surrounding pieces for natural contour. This method can yield more natural appearance of the tip and lobule. Our tip plasty technique combined with dorsal augmentation is very useful and effective procedure in the correction of blunt tip.