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.
7 Comments so far
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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!