Intradermal Hyaluronidase: The Answer to Treatment in Softening a Fibrous Thick Supratip Skin in Rhinoplasty?

Abstract

ABSTRACT
 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.
 METHODS
 A vial of 1,500 I.U. of hyaluronidase (Liporase, Skin Lab Medical, Essex, UK) is mixed with 1.0 ml of Normal Saline Solution (NSS) and 0.1 - 0.2ml (150u – 300u) is aspirated and may be diluted with 0.8ml of PNSS in a 1 cc tuberculin syringe or given as concentrated dose. Intradermal injection into fibrous thick skin can be performed intraoperatively before incision or after closure when defatting and tip grafts are put in place but still with supratip fullness. The areas to be injected are the supratip and its sides. (Figure 2).
 A disposable hypodermic needle gauge 30 is used to inject intradermally or subdermally in minute amounts until blanching is noted. These injections are given at equally random spacing. Immediately after injection, finger pressure massage is applied at the supratip area for 1-3 minutes to soften the skin and allow redraping of the skin and soft tissue envelope (SSTE).