The impact of skin thickness for rhinoplasty
The shape of the nose for the most part is dependant on the form and structure of the underlaying nasal skeleton. Therefore aesthetic rhinoplasty is essentially oriented on shaping of the underlaying bony and cartilaginous structures. The skin with its connective and fatty tissue lies over the base skeleton of the nose which is influencable by the surgeon. Since the skin envelope shows different thicknesses and influenced the tip of the nose more than the nasal bridge, the final result of a rhinoplasty depends on the interaction of skin thickness and bony-cartilaginous basis. Since you don’t want to place any visible scars on the nasal bridge, the extent of modification of the skin envelope is very limited.
The extent of alteration of the nose is skin thickness which is an only marginally influenceable factor by the surgeon. Extremes like very thin or very thick skin imply different operative steps in a rhinoplasty.
The influence of thin skin on the result of a rhinoplasty
In patients with ultra-thin skin scars often heal very well and swelling in the surgical area is rather minimal. However thin skin has only little camouflage potential to conver the underlaying nasal skeleton. Even the merest unevenness on the nasal bridge become visible. Therefore the biggest challenge in patients with ultra-thin skin is to operate extremely precise and to leave behind a smooth nasal bridge. Alternatively transplants can be grafted (fascia, dermis, cartilage) or injected to reinforce the skin thickness.
Thick skin: a challenge in rhinoplasty
Extremely thick skin covers the nasal skeleton very well over the area ove the nasal brideg, but is sadly a limiting factor when wishin for a small nose, especially a small tip of the nose. Patients often suffer from their big tip of the nose and broad, thick nostrils. The thick skin of the likewise enlarged tip of the nose is often felt to be to coarse in comparison to the fascial proportions.
Thick skin is not always the cause for a thick tip of the nose (so called boxy tip)- a relatively lage developed alar cartilage can make the tip of the nose look big in thin skin too. Extremely thick skin is a challenge for the surgeon. She acts firm and forms a resistance when it comes to the desired shaping of the smaller alar cartilage or a more defined tip of the nose. Surgical techiques that severely weaken the cartilage of the tip of the nose, rather result in a plump, compressed looking tip of the nose, as support is missing. In this case a structural stabilization of the nose and the achieving of a well-shaped not quite so small nose is advisable.
In this case I tell my patients that a shapely but slightly bigger nose looks better that a small, plump, ill-defined nose.
Thinning of thick skin
The thinning, meaning the removal of fat and connective tissue under the skin, especially of the tips of the nose is not without risk. If isolated skin is raised and thinned, more extensive thinning is possible, as though the entire skin envelope on the nasal bridge as well has to be raised as in a hump removal. Limiting factor is the vascular supply of the tip of the nose. The closely under the dermis laying net of supplying blood vessels mustn’t be damaged too much during thinning. A resulting impaired circulation would be a desaster. Therefore I highly emphazise the very careful thinning of the skin during the procedure. Even though often performing this, I never try to proceed too aggressively to avoid damaging the skin.
By now I make all of my patients with very thick skin aware of the possibility that after a primary rhinoplasty for example with removal of a nasal hump and shaping of the cartilages of the tip of the nose, a secondary procedure might be necessary after one year in cases where patients feel the tip of the nose appears too bulky and in which there has been a development of thick scars in the layer of connective tissue under the skin. In these substantially shorter secondary procedure the fibrous scar plate which is generally 1-3mm thick, is being removed and an aesthetically appealing result can be achieved.
Prolonged swelling of the nose with thicker skin
Thick skin tends to longer swelling of the nose and increased scar formation especially underneath the tip of the nose. In almost all patients with thick skin I saw the swelling persist 24-36 months. The final effect of the rhinoplasty can only be asssessed after this time.
In certain cases steroids can be injected into the thickened skin underneath the tip of the nose only several weeks after the operation, to avoid formation of forceful scars, respectively to reduce a stronger connective tissue reaction. Usually I inject patients ones- up to 4 times with a gap of 6 weeks in between. In extremely rare cases of very strong connective tissue reaction, this treatment may take a while until all signs of a strong connective tissue reaction have subsided.
What are the signs of thick skin?
Thick skin over the nose is recognized by various factors, it has:
lots of sebaceous glands
in the outer third, only skin and connective tissue make up the nasal wings
a broader, sturdy outer nasal wing indicates this skin
when palpating the tip of the nose, one recognizes the skin thickness when squeezing it between two fingers to feel if its thin or thick
As a rule of thumb for the swelling to go down
Thin or thick skin- both extremes have advantages and disadvantages:
Thin skin: swelling subsides fast, little camouflage
Thick skin: swelling persists longer, better camouflage
Until visibility of the final result after rhinoplasty, meaning untill the swelling has subsided, it usually takes :
in thin skin: about 1 year
medium thick skin: round about 2 years
thick skin: round about 3 years
When hearing these statements, many patients get scared. It’s inevitable for you to know these facts before the operation, to be prepared that an aesthetic rhinoplasty represents an operation that –if performed only once as a rule- leads to a lifelong change in your face. Therefore it’s worth the wait.
For reassurance I explain patients, that usually already after 3 to 4 weeks they will have a smaller, more well-shaped nose than before. The rest of the swelling is mostly a matter of 1-3mm, that our environment only rarely notices.
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