Thick Nasal Skin
3 December 2019 onur
Thick nasal skin is an issue that bursts the bubble of rhinoplasty (nose job) candidates and leads to disappointment even at the inquiry stage. There is no need to worry because your nasal skin is thick, thinking you will not get a good result. However, you should know that the “beautiful” nose that can be designed for you may not be the nose you “want”.
Rhinoplasty should not be thought of as a kind of “surgery with unlimited possibilities”. As with all aesthetic surgeries, there are some limitations in rhinoplasty. What sets the limits is the patient’s unique anatomy. Unfortunately, some anatomical features cannot be changed by surgery or can only be changed to a very limited extent.
The nasal skin is the anatomical layer that we can change the least during rhinoplasty. We do not remove skin in surgery, and there is almost no change in the covering skin surface area. There are minor exceptions to this, but they merely consist of the millimetric shaping efforts we make in critical areas (nasal wing, columella).
Therefore, we have to adapt the changes we will make in the cartilage and bone skeleton to the nasal skin.
Think of thick nose skin like a quilt spread over a bed. Imagine there is a walnut under this quilt. When you look from the outside, you can vaguely see the contour of this walnut. If there is only an apple-sized object under the quilt, an observer can notice the contours of the object below the surface. Now imagine a thin silk duvet cover on the same bed. And imagine there is a walnut under this cover. When you look from the outside, you can easily make out the contours of the walnut.
Thick nasal skin reduces the visibility of the cartilages underneath. It obstructs the visibility of the angled character of the nasal tip and of aesthetic surface structures. Thick nasal skin typically remains edematous for years after surgery and appears thicker than it actually is. The thick nasal skin creates weight after the surgery, pulling the nasal cartilages down and flattening their shape. In patients with thick nasal skin, the nasal tip is more likely to get deformed in the postoperative period.
Therefore, we adhere to the following principles when operating noses with thick nasal skin:
- In patients with thick nasal skin, the cartilage structures under the nasal skin should be designed larger, harder, stronger, higher, more angled and more angular so that these exaggerated contours can be noticed externally.
- It is preferable not to decrease the nasal tip height of patients with thick nasal skin, but rather to increase it.
- In patients with thick nasal skin, the cartilage of the nasal tip is supported with hard cartilage pieces to withstand postoperative pressure. Therefore, the nasal tip may harden after surgery.
- Patients with thick nasal skin are more likely to suffer a drooping nose tip (rotation/projection loss) after surgery. That is why your surgeon may lift the tip of your nose more than they should (anticipating that it will droop later).
- Thick-skinned noses will be shaped not by reduction but by augmentation.
- To augment the nose, additional cartilage sources may be needed even in primary surgery, albeit rarely.
Thick nasal skin also has some ups. The most important of these is its ability to camouflage. Each rhinoplasty leaves minor irregularities in the nasal structure. Thick skin camouflages them perfectly. Again, after rhinoplasty, the nasal skin tends to get thinner over the years. We call this “progressive skin atrophy after rhinoplasty”. Patients with thick skins are more resistant to progressive atrophy. So, in the long run, thick skin turns into an advantage.
Thick nasal skin grows markedly edematous after surgery, and we cannot see the details of the nasal tip for almost a year or two until this edema subsides. Unfortunately, this waiting period can be very stressful and upsetting for patients who have had rhinoplasty. While a satisfactory contour can be achieved even in the first postoperative month in a patient with a thin skin, a thick-skinned patient sometimes has to wait for years to see the ultimate result.
In patients with thick skin, we can perform some procedures (debulking, SMASectomy, steroid injection, ulthera, etc.) to reduce the thickness of the soft tissue at the nasal tip. These procedures can reduce the total thickness of the soft tissue layers, if not the skin, in selected patients. Soft tissue thinning procedures also have their own complications and disadvantages. Therefore, you need to discuss with your surgeon in detail and decide whether these maneuvers can be performed. For instance, in smokers, thinning the nasal skin may cause circulatory disorders and skin loss at the nasal tip; steroid injections may cause unpredictable thinning of the skin; ultrasonic/radiofrequency energy may cause burns and scar tissue formation on the skin.
Thick nasal skin is a matter that must be detailed in the consultation process before rhinoplasty. It is possible to shape noses with thick skins quite successfully, but it is very important for patient satisfaction to set realistic expectations before surgery. Don’t be discouraged because your nasal skin is thick, but make sure you understand the aesthetic goals and limitations correctly.
Take good care…
… of yourself and your beauty.