The Laryngoscope

C 2013 The American Laryngological,

V

Rhinological and Otological Society, Inc.

Ultrasonographic Evaluation of Long-term Results of Nasal Tip

Defatting in Rhinoplasty Cases
Shadman Nemati, MD; Rahmatollah Banan, MD; Ahmad Alizadeh, MD;
Ehsan Kazemnejad Leili, MD; Hassan Kerdari, MD
Objectives/Hypothesis: Nasal skin thickness has an important role in aesthetic results of rhinoplasty. The aim of this
study was to evaluate the long-term results of tip and supratip skin defatting technique in rhinoplasty subjects using
ultrasonography.
Study Design: Prospective, randomized, case-control study.
Methods: Among 111 rhinoplasty cases referred to a university hospital between February 2010 and September 2011,
after physical examination and measuring the nasal tip and supratip skin thickness by ultrasonography, a total of 55 patients
with thick and moderate skin were randomly allocated for rhinoplasty using one of the following methods: rhinoplasty with
(case group) and without (control group) defatting tip and supratip skin. Ultrasonographic evaluation of the skins was
repeated 1 and 12 months after surgery, and the data were analyzed by Wilcoxon and repeated measure tests using SPSS 17
software.
Results: Twenty-eight of 55 candidates (10 men, 45 women; mean age, 25.1 6 7.6 years) underwent skin defatting during rhinoplasty; the other 27 patients did not undergo this procedure. Forty-four patients completed the study. Thickness of
tip and supratip skin was not statistically different before surgery and during follow-up evaluations in defatting and nondefatting technique groups (P .7).
Conclusions: Defatting techniques have no effect on reducing tip and supratip skin thickness after rhinoplasty in moderate to thick skins.
Key Words: Rhinoplasty, skin thickness, defatting, ultrasonography.
Level of Evidence: 1b.
Laryngoscope, 123:21312135, 2013

INTRODUCTION
Rhinoplasty is an aesthetic surgery with high importance because of the central position of the nose in
the face.1,2 Skin quality is an important and essential
parameter determining the preoperative planning and
surgical outcomes in rhinoplasty cases.3 Early traditional nasal anatomic descriptions focused on the bony
and cartilaginous nasal skeleton as being the most important parameters in surgical alteration of the nose;
currently, however, the critical role of skin thickness and
its subcutaneous tissues is more keenly appreciated.3

From the Department of OtolaryngologyHead and Neck Surgery

(S.N., R.B., H.K.), Amiralmomenin Hospital, Guilan University of Medical
Sciences, Rasht, Iran; Department of Radiology (A.A.), Pursina Hospital,
Guilan University of Medical Sciences, Rasht, Iran; and Department of
Biostatistics (E.K.L.), Faculty of Midwifery and Nursing, Guilan University
of Medical Sciences, Rasht, Iran.
Editors Note: This Manuscript was accepted for publication
October 10, 2012.
All financial and material support for this research was provided
by the Research Office of Guilan University of Medical Sciences.
The authors have no other funding, financial relationships, or conflicts of interest to disclose.
Send correspondence to Shadman Nemati, MD, Otolaryngology
Head and Neck Surgery Department and Research Center, Amiralmomenin Hospital, 17 Shahrivar Ave., Postal code 41396-37459, Rasht, Guilan,
Iran. E-mail: nemati@gums.ac.ir
DOI: 10.1002/lary.23862

Laryngoscope 123: September 2013

Nasal skin thickness often has been attributed to

the increased subcutaneous tissue and glandular quality
of this area.3,4 The variation in skin thickness along the
nasal dorsum is well known to rhinoplasty surgeons. In
particular, in the lower third of the nose, the thickest
skin may be found in the tip and supratip regions.13
Thick skin with more hypodermic fat pad recovers
and contracts slowly and causes more edema and hypodermic scar formation after rhinoplasty and generally is
not appropriate for surgery because of undesirable outcomes.3,5 On the other hand, very thin skin is also not
appropriate; it seems that skin with moderate thickness
is more appropriate in rhinoplasty cases.5
The current techniques for evaluation of nasal skin
conditions include touching (i.e., physical examination),
photography, and occasionally radiography.6 A new
radiologic technique that recently attracted the attention
of surgeons and researchers was ultrasonography of the
nose.7,8 It is more economical than other imaging techniques, and high-resolution sonography provides quick
data for the nose structures, including skin thickness,
subcutaneous tissue, interdomal fat pad, muscles, and
cartilaginous and bony skeleton.713
The soft-tissue components under the dermis
include a superficial fatty panniculus, a fibromuscular
layer (superficial musculoaponeurotic system), a deep
fatty layer, a longitudinal fibrous sheet between the
Nemati et al.: Tip Defatting in Rhinoplasty

2131

Fig. 1. Tip and supratip skin defatting during rhinoplasty: delivery

approach. The subcutaneous fibrofatty tissues are dissected and
separated until the vascular layer of the skin is reached.

upper and lower lateral cartilages, and an interdomal

aponeurosis.1315 Unlike the superficial fatty layer, the
deep fat layer lacks fibrous septae and thus allows surgical dissection to be performed in an atraumatic
fashion.13
During rhinoplasty, optimal profile contouring
requires attention to the undersurface of the tip and
supratip skin as well as the soft tissue of the tip and
supratip. Skin defatting and soft-tissue trimming is one
of the surgical maneuvers to address this area, and
many authors recommend excision of excessive subcutaneous tissue in the nasal tip, commonly in thick skins;
however, this technique is not recommended for thin
skins.3,1416
In the current study, our aim was to determine the
effects of a nasal skin defatting technique on reducing
tip and supratip skin thickness in rhinoplasty cases. To
our knowledge, this is among the first studies in which
the long-term effects of nasal skin defatting have been
evaluated by an objective and accurate method (i.e.,
ultrasonography).

performed by one surgeon (S.N.) using one method (closed/delivery approach). For defatting the tip skin, before closure of the
marginal and intercartilaginous incisions, the inner surface of
nasal tip and supratip skin was delivered outside, and then the
subcutaneous fibrofatty tissues were dissected and separated
evenly and unvaryingly, until reaching the vascular layer of the
skin (Fig. 1). Approximately 1 cm3 of fibrofatty tissue was
extracted from the nasal tip skin undersurface of each case.
Postoperative orders and care were identical in both groups. In
all the cases and controls, noses were taped and casted, but the
internal splints were not used. Nose packing was used for 2
days and removed after that, but the nose casts and the tapes
were left in place for 6 to 7 days. The casts were then removed,
and new tapes were placed from the supratip dorsum to the
intercanthal line and from nasal left to the right sidewalls that
changed every 3 to 5 days for 1 month.
All the cases and controls were referred to repeat ultrasonography of nasal tip and supratip skin 1 and 12 months after
surgery (Fig. 2). All sonography studies were performed by one
expert radiologist/sonographer (A.A.) and with a single set during all stages; the sonographer was blind to the technique
applied during the surgeries (i.e., defatting or not defatting).

Statistical Methods
Statistical analysis was done using the statistical package
SPSS 17 (IBM, Armonk, NY). Normality of the distribution was
checked for each variable (one sample Kolmogorov-Smirnov
test). To verify changes of quantitative variables measured via
sonography before and after surgery, the Wilcoxon test was
used, and repeated measures test was applied to verify changes

MATERIALS AND METHODS

From 111 rhinoplasty candidates referred to a university
hospital between February 2010 and September 2011, we randomly selected 80 subjects, who provided informed consent for
participating in a cohort prospective study. Exclusion criteria
included smoking, allergic rhinitis, and a history of previous
rhinoplasty. The proposal for the research was approved by the
Research Office and Ethics Committee of Guilan University of
Medical Sciences. After physical examination of the subjects,
skin thickness of nasal tip and supratip was measured using
ultrasonography with high-frequency surface probes (10 MHz
probe, BK medical, Denmark). Skin thickness type in ultrasonography was considered thin when it measured about 2.2 to
2.6 mm, moderate when it was 2.6 to 3.1 mm, and thick
when it measured more than 3.1 mm.11 Subsequently, 55
patients with thick and moderate skins were randomly (using
systematic random sampling method) allocated into two groups:
rhinoplasty with tip and supratip skin defatting and rhinoplasty without defatting. All rhinoplasty procedures were

Laryngoscope 123: September 2013

2132

Fig. 2. Ultrasonography of a patient with moderate skin thickness

in whom defatting was performed during rhinoplasty. (A) Before
surgery: skin thickness at tip was 3.5 and 3.1 mm and at supratip
was 2.8 and 2.7 mm in right and left sides, respectively; (B) 12
months after surgery: skin thickness at tip was 2.7 and 2.7 mm
and at supratip was 1.7 and 1.9 mm in right and left sides,
respectively.

Nemati et al.: Tip Defatting in Rhinoplasty

TABLE I.
Preoperative Size of Tip and Supratip Skin and Lower Lateral
Cartilages Thickness Considering Sonography Results.
Variable

Thin Skin
(n 14), mm

Moderate Skin
(n 45), mm

Thick Skin
(n 21), mm

Right tip

2.6 6 0.7

3.1 6 0.6

3.2 6 0.7

Left tip

2.6 6 0.7

3.1 6 0.6

3.3 6 0.7

Right supratip
Left supratip

2.3 6 0.6
2.3 6 0.6

2.4 6 0.5
2.4 6 0.5

2.7 6 0.6
2.6 6 0.4

Data are presented as mean 6 standard deviation.

during the three times of measurement. Statistical j test was

used to review agreement between outcomes of clinical examinations and sonography results, and j closer to 1 was
interpreted as showing more agreement between the two methods (the most agreement was considered at amounts of 0.80 to
1). In this study, P < .05 was regarded as being statistically
significant, and the amount of P was reported as two tailed.

Fig. 3. Changes in thickness of defatted moderate/thick nasal tip

and supratip skins in rhinoplasty candidates. Sizes are shown in
millimeters.

complications, and all of the subjects, including those

who dropped out of the study and were followed up by
telephone, did not declare significant dissatisfaction with
the results of their surgeries after at least 1 year.

RESULTS
From 80 subjects out of 111 rhinoplasty candidates
with a mean age of 25.1 6 7.6 years, 12 (15%) were men
and 68 (85%) were women. According to clinical examination, moderate skin was observed in 45 subjects
(56.25%), thin skin in 14 (17.5%), and thick skin in 21
(26.25%) patients. Results of ultrasonography revealed
that skin was thin in five (6.25%), moderate in 60 (75%),
and thick in 15 (18.75%) subjects. These results revealed
that the least agreement was observed between the two
methods of skin thickness evaluation, so there was more
than 50% difference between them (j 0.19). Table I
demonstrates sonographic measurements of different
skin types before rhinoplasty.
Twenty-eight cases with moderate and thick skins
underwent defatting, and 27 cases had no defatting during rhinoplasty. Fifty-one subjects performed the second
session of tip sonography at the end of the first postoperative month, and 44 subjects (22 cases and 22 controls)
completed the study and underwent the third session of
nasal tip sonography 12 months later. Therefore we had
11 subjects who dropped out; the main causes of not performing postoperation ultrasonography were low
compliance with the orders (6 subjects) or wrongly performing the sonographies in other centers (3 subjects)
and immigration to other provinces or countries (2
subjects).
According to Figure 3, for example, in the right side
of the tip, the mean of measured skin thickness was
3.09 mm, and this measurement reached 2.7 mm and
then 3.3 mm at 1 and 12 months after rhinoplasty,
respectively. There were no differences considering
changes of defatted skin thickness during three different
times (preoperative and 1 and 12 months after surgery)
(P .7). Also, according to Figure 4, there was no significant difference in changes of nondefatted skin (P .3).
As we can see, the thickness of nasal tip and supratip
skin increased in 1 month after the surgery, probably
because of edema, and then, after 12 months, returned
back to the baseline. There were not any postoperative
Laryngoscope 123: September 2013

DISCUSSION
In our study, less agreement was observed between
the two evaluation methods of nasal skin thickness (i.e.,
clinical examination and sonographic verification). It
seems that clinical judgment is not a perfectly accurate
method for preoperative evaluation of nasal tip and
supratip skin thickness in rhinoplasty candidates.
Copcu et al. conducted a study on the effects of sonography before rhinoplasty and found that the size of
the nasal tip fat pad varied among individuals, but it
was very large in those patients with fatty skin and
onionlike nose.10 Moreover, Coskun et al. demonstrated
a meaningful relationship between thickness of fat pad
and surgery results in 23 rhinoplasty patients.11
Cho et al., in their study of 77 rhinoplasty candidates, verified nasal structure using preoperative
computed tomography scan and evaluated patients
results and outcomes; they demonstrated that the thickness of nasal tip skin was about 2.9 mm. Patients with a
thin nasal tip and average tip skin thickness of 2.2 to

Fig. 4. Changes in thickness of nondefatted moderate/thick nasal

tip and supratip skins in rhinoplasty candidates. Sizes are shown
in millimeters.

Nemati et al.: Tip Defatting in Rhinoplasty

2133

2.8 mm before rhinoplasty had excellent aesthetic

results in the follow-up period, but those with thick
nasal tip and higher average tip size of 3.4 mm had poor
aesthetic results. In this study, a statistically significant
difference was observed among those levels of aesthetics
regarding nasal tip skin thickness.12
Preoperative evaluation, one of the essential parts
of rhinoplasty, is routinely based on clinical examination
and consideration of patient photographs.17 These pictures provide surgeons with information regarding
surface anatomy but not information on nasal bony and
soft-tissue structures. This information can be useful in
satisfying the patients after surgery and also for medicolegal reasons.18 Face sonography can be used for
different purposes. According to recent studies, sonography has potential capabilities in determining nasal soft
tissues and layers.19,20 Friedrich states that sonography
is one of the useful instruments in some specialized
fields of medicine because it is safe, noninvasive, inexpensive, available, and can be safely used due to lack of
radiation. Its only problem relates to the skill and proficiency of the sonographers, which can affect the
reported results.21
Similar to all previous studies, our study revealed
that ultrasonography is an excellent method in evaluation of nasal tip soft-tissue thickness.
Tasman and Helbig used sonography to evaluate
nasal tip anatomy and stated that the width of the nasal
tip was 1.8 to 2.4 centimeters.22 In their study, a meaningful relationship was observed between width of nasal
tip before surgery and nasal intermodal distance and
width of nasal tip after surgery and skin thickness.
They proposed nasal skin thickness as a limited factor
in nasal tip correction and reported a significant relationship between nasal tip skin thickness and surgical
technique. They declared that transdomal suture could
not make an acceptable narrowness for nasal tip when
skin was more than 4 mm thick, and this technique
might be ideal for skin thicknesses of 3 mm or less.22
Tasman and Helbig introduced cartilage splitting,
tip scoring, or defatting as the best techniques for thick
skins, and they concluded that nasal tip sonographic
study may be helpful in finding the best technique.22
Some other authors have recommended excision of excessive subcutaneous tissue in the nasal tip, especially
in thick skins; however, they do not recommend this
technique for thin skins.3,14,15 To our knowledge, all of
these recommendations are just expert opinions that
have the lowest level of evidence, and no structured
study of the efficacy of this technique has been reported
in the English literature.
Contrary to these suggestions, our study demonstrated no statistically significant difference considering
reducing skin thickness in patients with defatted thick
skin before surgery and 1 and 12 months after surgery.
Although in both groups other confounding factors such
as patient age, preoperative thickness of nasal skin,
manners of the surgeon, and postoperative orders and
care were identical, no one can deny the role of postoperative edema or scarring in the defatted group compared
with the control group.
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According to our study, the defatting technique in

rhinoplasty does not meaningfully affect nasal tip skin
thickness, and it seems that the defatting technique is
not a useful method in rhinoplasty for normal and thick
skins, especially when considering the fact that it can
increase the risk of hemorrhage during the surgery, it
increases the operation time, and it also has some other
risks such as scar formation and skin atrophy. Therefore, it is recommended that skin defatting be avoided
during rhinoplasty. Further studies may be needed
regarding why the defatting techniques do not work in
rhinoplasty cases, but one can consider regrowth of the
subcutaneous adipocytes or formation of fibrous tissue at
the site of dissection/defatting in these cases. Also, further studies of the aesthetic outcome of the defatting
technique may be useful.

CONCLUSION
Similar to previous reports, this study showed
ultrasonography as a valuable instrument in assessing
nasal tip and supratip skin thickness before rhinoplasty.
Defatting techniques had no long-term effects on reducing tip and supratip skin thickness after rhinoplasty in
moderate to thick skin types.

Acknowledgments
The authors give special thanks to Parviz Dolati, MD,
neurosurgeon and fellowship of clinical endovascular surgery at Calgary University, Canada, who revised the
manuscript; to Ali Tabrizi, MD, Mohammad Aghajanpour,
MD, and Mrs. Maryam Nuri, who aided us in preparing
the manuscript; and to the Research Office of Guilan University of Medical Sciences, which provided all financial
and material support for this research.

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