Clinical Review & Education
Surgical Pearls | AAFPRS ADVANCES IN RHINOPLASTY FEATURED ARTICLE
SMAS Debulking for Management of the Thick-Skinned Nose
Eugenia Chu, MD; Richard E. Davis, MD
Introduction
One of the greatest challenges in cosmetic rhinoplasty is the overly
thick nasal skin envelope. In addition to exacerbating unwanted na-
sal width, thick nasal skin is a major impediment to aesthetic refine-
ment of the nose. Owing to its
bulk, noncompliance, and ten-
Video at dency to scar, overly thick skin
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frequently obscures topo-
graphic definition of the nasal
framework, thereby limiting or negating cosmetic improvements.
Masking of the skeletal contour is usually most evident following ag-
gressive reduction rhinoplasty where overly thick and noncompli-
ant nasal skin fails to shrink and conform to the smaller skeletal frame-
work. The result is excessive subcutaneous dead space leading to
further fibrotic thickening of the already bulky nasal covering. De-
spite the decrease in nasal size, the resulting nasal contour is typi-
cally amorphous, ill-defined and devoid of beauty and elegance.
To optimize cosmetic results in thick-skinned noses, contour en-
hancement is best achieved by elongating and projecting the skel-
etal framework whenever possible (Figure 1). Skeletal augmenta-
tion not only reduces dead space to minimize fibrotic thickening, it
also stretches and thins the outer soft-tissue covering for im-
proved surface definition. However, in noses in which the nasal
framework is already too large, skeletal augmentation is not a vi-
able option, and the overly thick skin envelope must be surgically
thinned to achieve better skin contractility and improved cosmetic
outcomes.
Figure 1. Amorphous Nose With Ultrathick Skin
A B
C D
E F
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Histologic examination of overly thick nasal tip skin reveals com-
paratively little dermal thickening or increased adipose content but
ratherasubstantialincreaseinthicknessofthesubcutaneousfibromus-
cular tissues.1 Dubbed the “nasal SMAS” layer,2 the fibromuscular tis-
sue layer lies just beneath the subdermal fat and may account for an
additional 2 to 3 mm of skin flap thickness. Owing to a discrete dissec-
tion plane separating the nasal SMAS layer from the overlying subder-
mal fat, surgical excision of the hypertrophic nasal SMAS layer can be
performed safely in healthy candidates using the external rhinoplasty
approach.3 However,theoverlyingsubdermalplexus(containedwithin
the subdermal fat) must be carefully protected.3-5 Similarly, inadver-
tent disruption of the paired lateral nasal arteries—major feeding ves-
sels to the subdermal plexus—must also be avoided, and special care
should be exercised when working near the alar crease.3-5 SMAS de-
bulking is also contraindicated in skin less than 3-mm thick because
overly aggressive surgical debulking may lead to unsightly prominence
of the skeletal topography. However, in the appropriate patient, SMAS
debulking can reduce skin envelope thickness by as much as 3.0 mm,
with greater reductions common in revision rhinoplasty cases when
vascularity permits.6
Surgical Technique
The nasal framework is first degloved in a subperichondrial dissec-
tion plane using the external rhinoplasty approach. Once skeletal
modifications are complete, thickness of the nasal skin envelope is
measured (Figure 2A), and targeted areas are identified. Skin flap
thickness in excess of 5.0 mm is considered “ultrathick” and appro-
Amorphous nose with ultrathick skin.
A, C, and E, Preoperative anterior,
lateral, and basal views, respectively.
B, D, and F, Corresponding 2-year
postoperative views following (1)
dorsal augmentation with diced
cartilage–fascia graft, (2) increased
nasal tip projection with septal
extension graft, and (3) nasal tip
refinement with tip sutures and nasal
SMAS excision in the midline supratip
and supratip sidewalls. Note
improvement in nasal definition and
contour obtained through combined
skeletal expansion and SMAS
debulking.
(Reprinted) JAMA Facial Plastic Surgery Published online May 15, 2015 E1
 Clinical Review & Education Surgical Pearls

Figure 2. Nasal SMAS Debulking

A B

A, Measuring nasal tip skin thickness

using a sliding Boley caliper.
B, Dissection of the nasal SMAS flap
from the undersurface of the
subdermal fat. Note the distinct color
difference between tissue layers.

priate for SMAS debulking when vascularity permits.4-6 Individual
patterns of skin thickness vary widely from nose to nose, and wide-
spread debulking is seldom indicated. SMAS debulking is most com-
monly performed in the midline supratip and frequently along the
supratip sidewalls and/or infratip lobule. In rare instances, a large por-
tion of the middle vault may benefit from SMAS excision. In con-
trast, SMAS excision directly over the nasal tip lobule is rarely indi-
cated because unsightly prominence of the dome units and/or tip
grafts may result.
Debulking is initiated with a shallow incision through the cau-
dal border of the SMAS dissection zone (Video). In primary rhino-
plasty, SMAS elevation can be accomplished with a blunt tech-
nique using scissors, a Cottle elevator, or even a cotton swab. For
revision cases, sharp dissection is occasionally needed to release fi-
brous scars from the subdermal fat. Countertension on both cor-
ners of the SMAS flap with Adson-Brown forceps is used to delin-
eate the anatomic dissection plane between the reddish-colored
SMAS tissue and the pale yellow subdermal fat (Figure 2B). Dissec-
tion along this relatively bloodless interface ensures symmetry and
uniformity of the skin flap and maximal thinning of the soft-tissue
envelope while simultaneously protecting the nasal plexus. When
the upper border of the dissection zone is reached, a beveled cut is
used to produce a smooth transition without step-off deformity.
Discussion
Without meticulous aftercare, the benefits of SMAS debulking will
be negated.5,6 To minimize cutaneous thickening from subcutane-
ous fibrosis, prevention of swelling and inflammation is the pri-
mary goal of aftercare. Prevention begins intraoperatively with con-
trolled hypotension using narcotic-free general anesthesia,
atraumatic soft-tissue technique, limited use of electrocautery, and
a gentle cinch-type nasal dressing. Perioperative antiemetic pro-
phylaxis, antibiotic prophylaxis, and prompt treatment of hyper-
tension further limit nasal swelling. Capillary refill and nasal tip color
are monitored closely in the first 12 to 24 hours to ensure adequate
nutrient blood flow. Continuous elevation of the head and applica-
tion of ice are initiated in the recovery room, and patients are in-
structed to avoid supine posture, exercise, salty foods, or sun ex-
posure until all acute swelling subsides. A moist washcloth is placed
over the nose and upper face, and nonlatex gloves filled with crushed
ice are positioned over the eyes and medial cheeks. Ice is reapplied
continuously throughout the first night after surgery and daily for
several days. Topical nasal steroids are initiated after 2 weeks, and
low-dose triamcinolone acetate injections (5-10 mg/mL) are initi-
ated if persistent swelling is evident after 1 month.5,6 Injections are
repeated at 4- to 6-week intervals as needed, and dosing is titrated
to effect.
Conclusions
Although thick nasal skin naturally resists contour enhancement, a
strong and well-projected skeletal framework, combined with me-
ticulous aftercare and SMAS debulking in selected patients, will of-
ten result in substantial cosmetic improvement and a satisfactory
surgical outcome (Figure 1).

ARTICLE INFORMATION
Author Affiliations: Division of Facial Plastic
Surgery, Department of Otolaryngology, The
University of Miami Miller School of Medicine,
Miami, Florida (Chu, Davis); The Center for Facial
Restoration, Memorial Miramar Hospital, Miramar,
Florida (Davis).
Corresponding Author: Richard E. Davis, MD,
Center for Facial Restoration, 1951 SW 172nd Ave,
Ste 205, Miramar, FL 33029
(DrD@DavisRhinoplasty.com).
Published Online: May 15, 2015.
doi:10.1001/jamafacial.2015.0361.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This study was presented
at the AAFPRS Advances in Rhinoplasty 2015
meeting; May 15, 2015; Chicago, Illinois.
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In: Azizzadeh B, Murphy M, Johnson C, Numa W,
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Additional Information: Dr Davis is responsible for 4. Rohrich RJ, Gunter JP, Friedman RM. Nasal tip
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