Feb 21
Why does my skin thickness matter?
Skin quality and thickness is one of the most important factors in determining your final Rhinoplasty result. And it can also be one of the hardest to predict. When we perform Rhinoplasty, most of what we do involves altering the cartilage and bone that makes up the nasal skeleton. We shape the cartilage and bone in many ways to take on the new desired contour. During the healing period for many months after surgery, the skin and soft tissue that lays over this skeleton must contract inwards and ’shrink wrap’ onto this altered framework for the desired changes to become noticeable. That’s why you don’t see real definition for weeks to months after surgery while the skin and soft tissue is swollen.
Most people have skin of moderate thickness. The thinner your skin, the faster and better it will contract. So, if you have very thin skin, you can expect over time that a lot of definition can be achieved. This has obvious advantages but may also have its disadvantages. Thin skin will allow for a high degree of refinement but any tiny irregularities or asymmetries may also show through. This can be especially true if you have thin skin and very strong prominent cartilage underneath. You can recognize this in someone whose entire tip cartilage outline can be seen easily through the skin. We may recommend in certain circumstances using a layer of material such as fascia or acellular dermis (Alloderm) during surgery as a thin cover and concealer to help smoothen out your final look.
At the other extreme is very thick skin. Thick skin readily conceals any tiny irregularities. However, it can be much more difficult to achieve the desired level of definition and refinement because sharp lines and angles can appear blunted under a thick cover. Sometimes it is just not possible in this scenario to achieve very sharply defined features. There are some things we can do to improve definition, though. If your skin is very thick and you want increased definition, we may use larger tip grafts or dorsal grafts (on the bridge) to compensate. We may also judiciously thin out the fatty tissue under the skin, especially at the tip, to achieve more refinement.
Another potential pitfall occurs when a thick-skinned nose must be reduced significantly in size. Thick skin tends not to contract as much or as quickly as we might like after surgery. If the nasal tip or bridge is reduced too much, the space in between the reduced nasal skeleton and the skin can fill in with scar tissue over time. The result can be a nose that may be somewhat smaller, but is amorphous in shape and poorly supported. It tends to look a little ‘blobby’ once healed and patients often end up unhappy because they wanted a small, refined nose instead of a small, unrefined one. To avoid this outcome, we will usually recommend reducing your nose a little more conservatively in this situation. Thick skin requires more support, so leaving a strong nasal framework is an especially good idea in this setting. A very nice and dramatic result can still be had and a moderately smaller, but refined, nose will tend to look much better for you. Sometimes we can push along the skin shrinkage with steroid injection and having you tape your skin at night for an extended period after surgery to achieve the optimal result. It’s important to keep in mind also that thicker-skinned patients will usually take longer to see the degree of refinement they want, sometimes up to 2 years or more after surgery.
The good news is that an experienced Rhinoplasty surgeon can get a good sense of your skin type, thickness, and quality during your assessment, and give you a very good idea of what results can be expected or achieved. Your skin thickness should also be taken into account during surgery when changes to your nasal framework are made. This will render post-operative healing more predictable.
If you have particular questions related to your skin thickness, feel free to post them and we’ll get back to you as soon as possible.
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Your blog made me feel a lot better. I had rhinoplasty in August 07, and at times feel like my nose looks the same if not bigger! My surgeon keeps insisting I have extremely thick skin and so it will take at least 18 months for the swelling to go down. I fing that in xtreme cold or warm weather it swells, so was beginning to think I had wasted $6500.00 and wanted to get a revision done right away. It will be 7 months April 7th. Hopefully I will get the result I was hoping for…still waiting.
Hi Mishelle,
Thank you for taking the time to comment. We’re glad the blog was reassuring and consistent with your surgeon’s advice. We feel your frustration. Thick skin can take a long time to settle.
The fact that the swelling fluctuates is a good sign. When it no longer fluctuates, you are approaching the final result. Hopefully, by 7 months, you should also be seeing some positive changes. If you’re starting to like the look of things when it is least swollen, then you are headed in the right direction. Certain things like extremes of temperature, exercise, laying down for long periods, stress, lack of sleep, etc. will tend to make it look bigger for a while.
Try not to pay too much attention to this up and down movement. You have a fair bit of refinement left to occur. Be sure to continue to voice concerns over your progress with your surgeon. He’s the only one who can tell you what was done and what to expect for your particular case. Good luck, and we hope you love your result.
Dear Beverly Hill Rhinoplasty,
I had a 2nd rhinoplasty done in Sept 07, I was happy with the width & height of the 1st outcome, but there was a bump & uneven tip. The 2nd surgeon took down the bump, but much to my horror increased the size of my nose with AlloDerm. I thought that it was swelling until I received the op. notes. And indeed she noted that the goal was to make a larger nose. I am very upset, is there anything that can be done to return my nose to the width & height I had when I went into this? Thank you
Dear A,
It is often possible to reduce the nose and make it
smaller, even in revision. Considering the alloderm was placed about 8-9 months ago, you may be finding that with time the alloderm is slowly resorbing on its own.
Our concern is that you said the operative note said the intent of surgery was to make your nose bigger. If that is the case, its less likely that the alloderm is the main reason your nose is bigger. Lastly, and perhaps most importantly, remember that this was your second
surgery and often the swelling takes much longer to resolve in revision, so you may just need to be patient.
Feel free to contact us via email or phone and send us pictures or come in for a visit, so we can better help determine how we can help you.
Thank you very much. The op. notes states that the implant was placed along the bilateral dorsum, and that the irregularity at dorsum was reduced with a rasp. A pocket was created to insert the alloderm. I was hoping that the alloderm could be removed & my nose would go back. But I have noticed that my nose feels very bumpy, and still quite painful. I am making an effort to be patient, but I am very unhappy with the way it looks. Thank you again. Your help has been much appreciated.
Antonia
Dear A,
Operative notes can help, but they don’t always tell the full story. You mention feeling some bumps. Alloderm may have been used in your case to cover any grafts or small bumps, even after trying to smooth out the dorsum with a rasp.
Alloderm works by providing some thicker cover over thin areas. Eventually, it is mostly absorbed and replaced by scar tissue. So, unfortunately it can’t just be removed as you had hoped.
We know it’s hard to wait to be happy with your nose, especially the 2nd time around. But, 9 months is still a little early. You may find over the next 3 to 6 months that things start to settle down and smoothen out, and that your nose continues to get smaller. Sometimes, taping your nose at night can help this go faster.
Feel free to send us some pics. They won’t be posted. If you’re close by, drop in so we can talk about your concerns in more detail. We hope you’ll be happy, but if things are moving in the wrong direction, rest assured that improvements can usually still be made.
Thank you very much. I am in MA so I can not stop in. I really appreciate all of your help. This has been difficult for me. I really hope that it does get smaller, but I do not think it will be as small as when I went in. She did make a statement to me that it is not as large as it was, but closer to it(my God given nose). That was not the goal at all. She also stated in her op notes that the patient wanted to return to a larger nose. This is why I am so upset. I never wanted that, and even if this nose does get smaller, it was not designed to be as small as it was. I will need further surgery. Which is very emotionally taxing & expensive. But at least I have hope that I am not stuck w/this. All of your advice has been very helpful. Thank you so much for listening & trying to help!
I just had rhinoplasty and was informed I had “thick skin” and couldn’t achieve a huge difference, which upset me a lot because I’ve wanted to get this done since I was 12 and I’m 26 now. I always knew I;d be prettier with a little bit smaller less projected nose. Anyways my surgeon did osteotomy (to make it less wide) and other things, but I’m scared i’m going to be dissapointed because of this thick skin thing! I have minimal bruising under my eyes which makes me worry because shouldnt you bruise A LOT if your bones were broken in your nose? The computer imaging results he showed me were nice, not perfectly how i wanted my nose but i know that might not be possible. But I was still happy with those image resluts, but I;m afraid it might not even be close, he said I’d be happy to please, but if he could get to those results I will be happy. I know when he takes the splint off Its going to be swollen and I will be upset, I still think the tip looks too long or big but i know it’s stil very swollen. When can i compare my results to the computer and see how close they are?
Dear Elise,
I’m sorry it has taken so long for us to get back to you. By now, I suspect you have gotten your cast off and hopefully you are happy with the results your surgeon was able to get you.
In answer to your questions:
1. The vast majority of our patients have minimal if any bruising, though we do osteotomies in the great majority of our patients. It is not necessary that you bruise and if the fractures are done correctly you can often be spared heavy swelling or bruising, so you not bruising may be a good thing.
2.If the tip still looks too long/ projected after the cast goes off, it is a question of degree. Obviously, there is a bit of swelling that takes months to subside and in general by 3 months after surgery you are very close to your final result and should be pretty close to the imaged pictures. If it is not much different than before surgery, it is possible your surgeon did not de- project you, and this will likely not change with time.
We sincerely hope this helps answer some of your questions. Feel free to email us or call if we can be of more help.
Thank you very much for taking the time to post this valuable information!
How do you define “thick” skin?
What are the characteristics of an individual with thick skin?
Is thick skin more prevalent in certain ethnic groups? If so, what groups?
The thick vs. thin skin debate seems to be a nagging question among rhinoplasty patients, but I have yet to read a definition of “thick skin”. How can one determine if they have thick skin?
I hope you can take the time to answer my question.
Thanks again!
Hi Ron, thanks for your insightful question. There is no textbook definition of thick versus thin skin. It is a ‘feel’ thing that surgeons learn with experience after evaluating and then operating on many noses. It should be noted that we are not just talking about the skin itself, but the thickness of the fibrous/fatty tissue pad beneath the skin that overlies the nasal cartilage. Thin skin contracts and heals faster after rhinoplasty and may show more detail of the cartilage underneath, whether good or bad. Thicker skin takes quite a bit longer to shrink and achieve final contour. We may encourage a more defined look by thinning the fatty tissues under the skin in some cases.
Most people will be able to tell if they have oily, sebaceous skin. These skin types tend to fit into the ‘thicker-skinned’ category. So, some Caucasian noses may be more thick-skinned than others. Geography has a lot to do with it. Caucasians of more Northern ancestry for example, such as the British Isles, usually have thin skin. Those from more Southern regions, such as nearer the Mediterranean, will tend to have thicker nasal skin.
In general, patients of other ethnic groups, including African, East and Central Asian, and Hispanic origins fall into the thick-skinned category. Of course, there is a huge amount of variation within groups. So, your best bet is to visit your prospective surgeon and find out where you fit in.
I had a revision open-rhinoplasty in Dec 2008. Post=op I was EXTREMELY (freakishly) swollen. I am now about 16 months post op and while I am for the most part happy, the lower 1/3 of my nose (tip) is still swollen (which does fluctuate – sometimes more swollen than other times – with temp, etc).
I had a knobby tip that remained after the first surgery and the main goal of the revision was to refine the tip and get rid of the “knobs”. However, now I feel like my tip is bigger and less defined – esp in the supratip – than it was before (althougth the “knobs” are gone and the overall look is more streamlined). It also seems to be more swollen/puffy (the skin isn’t shrinking) on one side more than the other (apparently he did more work on this side).
It can look (esp in photos with flash) very amorphous and bulbous. I was told that my skin isn’t necessaryily thick but is just having a very hard/slow time contracting around the structure. My Dr. said I looked great on the OR table and just thinks I am having a very slow (rare) healing process and it eventually will get better. I have had a few laser treatments to help tighten the skin and move the healing process along – they did help a bit.
But I’m starting to lose hope and it’s a bit depressing…Any insight?
Hi Jessie,
I’m sorry to hear you’re still having issues with healing after rhinoplasty. In people with thick skin or if the tip was deprojected a lot, it can take a long time for the skin to shrink and settle appropriately. Revision cases may take even longer. The fact that you are still noticing some fluctuation is a good thing. If you like the way your tip looks when it is least swollen on good days, then you should find that it continues to settle to that level with time.
If not, I would suggest you take your concern up with your surgeon again. The key is to try to help the skin wrap quickly enough so that it does not encourage scar tissue to be layed down in the intervening space. It may be that steroid injection will still be helpful even over a year after surgery, although less so than in the first few months. If your surgeon does not seem to be addressing your concerns, another opinion may be helpful at this point.
I had rhinoplasty surgery exactly 7 weeks ago. There has been no change in my nose at all. My main concern has always been the width of my nose(I am African American). Post surgery, my nose is exactly the same. I know there might be swelling but shouldn’t i be seeing a difference no matter how minor? Pre-surgery my surgeon said I had think skin.
meant to say THIN skin
Hi Naomi,
How much of a difference you are seeing now really depends on how much was done during your surgery. In most cases of rhinoplasty in African Americans, the nose was narrowed enough that you should be seeing some improvement at this point. It may still look puffy without as much definition as there will eventually be, but by 2 months you should be starting to appreciate the change. If the goal was a less dramatic change, it will take longer to see the intended result. Talk to your surgeon. We have found that early intervention works best to help thicker skin settle faster.
hi. i had rhinoplasty surgery done 10 days ago. i used to have a large nose and my main issues were the width of my nose which was very wide and the tip, which was HUGE! after surgery i can see a difference in the width but im still concerned about the tip. my doctor says i have “thick skin” so he could only work with as much as was allowed. the tip and centre of my nose look very round. this bothers me. could this be due to swelling? my nose is still quite sore. when will i start to see a difference? i’m beginning to get depressed… thnak you.
Hi Samiera,
Thanks for your comment. The best thing to do is talk to your surgeon to get an idea of exactly what was done to your tip and what sort of change you can expect. At 10 days, you still have a lot of swelling that needs to settle. Check out our blog on swelling http://www.rhinoplastyinbeverlyhills.com/swelling-after-rhinoplasty and you’ll see that there is still noticeable swelling a few months after surgery with a lot more definition achieved after one year. With thick skin, this can take a little longer depending on what was done. So, have faith and talk to your doctor. All the best.
I had an extensive open septo/rhinoplasty a year and a half ago. I had my nose deprojected, a dorsal bump removed and the tip narrowed/balanced a bit. The biggest dissapointment I am feeling is that my tip is bigger and less defined than before. Is there a possibility that it could improve on its own? What could be done if it doesn’t. I used to have what i would describe as a narrow, defined, pointy tip, now its big and round and less defined. Help!
Hi Lynn,
Sorry to hear your result is not what you had hoped it would be. An apparent loss of tip definition usually happens when the surgeon either did not support the tip adequately or tried to deproject the tip too much. As a result, the skin can’t drape appropriately on the tip cartilage and instead looks round and lacking in shape. After a year and a half, you may not see much more spontaneous improvement. Steroid injections may help but usually not dramatically. At this point, you might look into options for revision. The good news is that your nose can most likely be revised to achieve the definition you want. Feel free to send us some photos on our contact page http://www.beverlyhillsprofiles.com/contact-us and we can set up some time to talk.
I had my rhinoplasty 2.5 months ago. I found comfort in this article as my skin is very thick and the reduction was moderate. I also found substantial supportive evidence in the truth that the swelling changes by taking post operative pics with my cell. My tip is much more swollen today than it was a month and a half ago. Proof that there is a healing process happening.
The best thing I have taken from this article is to continue to tape my nose. I find this greatly supports the framework and takes away the strange shifting sensations and discomfort. Also I had no idea that my scenario is a potential candidate to develop blobby scar tissue. We are always rushing things and want immediate results. We need to give our bodies a chance to heal. I was wondering if continuing to use an ice pack at night when my nose is peak swelling would be useful?
Hi Annalee,
Thanks for your comment. I’m glad you found the article helpful. Icing your nose at this point is not really going to do much. It may temporarily shrink the tissues a bit so it might be helpful to use before an event. We recommend instead to tape for a night or two before an event where you are taking photos. We would completely agree that giving yourself time to heal is a great attitude and sometimes the hardest thing to do. All the best.
Hello,
Over the past twelve years, I have gone through a few nasal surgeries. In 1998, I had two rhinoplasty surgeries performed primarily to narrow the bridge as much as possible. At first, post surgery, my nose looked perfectly narrow and thin. I was told to massage the nose, but my doctor did not spend a great deal of time instructing me on how to perform the exercises. As a result, my nose began to widen (which is extremely frustrating because it looked perfect). In 2002, I had an implant placed on the bridge of my nose (I met with a doctor and he thought my skin would drape better if an implant was inserted). My nose looked narrower, but I still wasn’t 100 percent satisfied. Approximately 3.5 weeks ago, I underwent another rhinoplasty in which another doctor performed ostetomies on my bridge to narrow it more. My bones feel narrower at the breakage point, and in certain lights, my nose appears narrower, but in other atmospheres I don’t feel like my skin is draping the way I would like it to in order to achieve that narrow / refined look. My doctor injected a steroid two weeks ago and said the cortisone would manifest itself in my nose and the effect would come over time. I think this time around, I have been performing the “nasal exercises” correctly, but I’m still concerned that the skin is not draping around my nose the way it should be. Would taping the nose at night help? Any feedback would be greatly appreciated and perhaps we could set up a time to chat if you are available. I’m a little depressed that I don’t quite have the result I want.
Hi,
The fact that your bridge feels narrower and looks better in certain lighting is an encouraging sign. The steroid injection should help the swelling go down faster. We do find taping helpful for our patients, not in improving the overall result but in getting patients there and feeling socially comfortable a little bit faster. Talk to your surgeon about taping and other efforts to improve your healing. If you still feel that your result is not as expected after about 6 months, that would be an appropriate time to start talking about your options. All the best.
Thanks – I saw my doctor today and he said that I have done a great job exercising my nose over the past three weeks, and that my bone is maximally narrowed (if he uses two fingers to slowly pinch the point of breakage, it takes him a couple of seconds to find the bone due to the space between the skin and the bone. His thoughts are that the skin is going to drape much more. In three weeks, he said he’d inject me with another steroid in higher volume (not stronger dosage) around the walls of my bridge, etc.
He didn’t think taping would help me. As of Thursday I will be four weeks post op. How much can I really expect my nose to drape to give me that really narrow effect which I desire? Just curious to hear your thoughts
Hey, i just got my septo-rhinoplasty done on the 3rd of august and i was told i have thick skin and i wont be able to get a very defined tip. However, i can see the tip of my nose and it looks lifted up a bit too high and my nostrils look larger and wider.. Is this normal? I’m starting to worry my nose will look like a pigs nose :/ i just turned 18 and i hope i didnt make the worst decision of my life yet. Please help!! Thank you!!!!
First I enjoyed reading your article and going through your website.I had rhinoplasty/septoplasty 9 days ago. I used to have dorsal humps and my nose was overall crooked. Even though I see a drastic change in my nose shape, the thing that is bothering me is my nose tip. It is extremely round and bulbous. I know its swollen because its very stiff and hard. Im afraid its going to take way too long to go down and i also read some intimidating stories online where people had the same problem and it never changed. Is that possible? The swollen tip makes my nose tip look very fake and plastic-like. Is there any thing i can do to speed up the healing process such as taping it?
Thank you so much!
U
Hi Uniska,
We’re glad you enjoy the site. At 9 days after surgery, there is still a fair bit of swelling that needs to settle. If your tip is far more swollen than before surgery, I would suggest paying a visit to your surgeon to be sure all is healing as it should be. Taping can be helpful but talk to your surgeon first. All the best,
Hi!
My daughter had a second rhinoplasty about 7 weeks ago. Her tip is still hard. My question is… will the length of her nose (profile) shorten as the swelling goes down? Does it take longer for swelling to go down the second time. Can the swelling in the tip cause it to look like it is drooping?
Thank you so much!
Pam
Hi Pam,
I hope your daughter has a terrific result. It can take longer for swelling to settle after a second nasal surgery. While that is the general rule, it really depends on what was done during the procedure. Likewise, it is possible for the tip to rotate upwards or downwards slightly after the procedure depending on what was done. Your best bet is to speak to your daughter’s surgeon to determine exactly what was done and what you can expect in terms of tip changes. In the first few months after surgery, swelling in the tip and the infratip (the area just below the tip) can cause that area to look more full. It should flatten and settle with time. Hope it works out great for you.