THIN SKINNED VS THICK SKINNED RHINOPLASTY (Washington DC, Virginia & Chevy Chase Maryland)

Rhinoplasty involves meticulous, precisely planned out maneuvers, on the nasal skeletal architecture – beneath the nasal skin. These maneuvers involve reduction, augmentation, or rearrangement of the cartilage and/or bony framework. These precise Rhinoplasty techniques on the nasal framework are done in order to see the final results through the skin. “All the surgical work during Rhinoplasty is usually done beneath the skin, but the results are seen by the patient and the world from above the skin.”  The only exception is nostril reduction where the surgery is directly on the nostril skin.

Now imagine “fixing your bed” at home. If you have a thick, heavy, Down Comforter covering everything as the final “layer,” then wrinkles in the actual bed sheet will not be seen. Even a walnut or a ping-pong ball, under this heavy, thick comforter may not “show!” But if instead of a heavy, thick comforter, you used a thin, Linen bed cover, as the final “layer,” then any small imperfections in the mattress or bed sheet would be readily “visible” beneath this thin Linen sheet.
Now imagine going camping and “pitching a tent.” If your tent is made of a very heavy, thick canvas then you need a strong tent pole in order to hold it up and have a nice shape to the tent. The thick, heavy fabric will weigh down a weak tent pole, and you will not be able to give your tent proper definition and shape. On the contrary, a much less sturdy tent pole can hold up a thin fabric. If anything, the tent pole may actually be “too visible” through the thin fabric.  This analogy applies to thick and thin skinned nose job patients.  Basically in thick skinned nose job patients, cartilage and structure needs to be added in order to create a more refined nose with definition, while in thin skinned nose job patients cartilage is removed to create refinement and definition.

Here are some general rules for Rhinoplasty patients with thin skin and Rhinoplasty patients with thick skin:
THIN SKIN RHINOPLASTY:

  • Very small surgical maneuvers will show as significant visible changes in thin skinned patients
  • Rhinoplasty patients with thin skin do not have a significant subcutaneous fatty layer beneath their skin. Therefore, post-operative steroid injections to prevent excess scar tissue development are usually not necessary or even advisable in Rhinoplasty patients with thin skin.
  • Rhinoplasty patients with thin skin often do not have as much post-op edema or swelling.
  • Extremely meticulous surgical technique must be used in Rhinoplasty patients with thin skin to prevent asymmetries or irregularities from “showing through” the thin skin after surgery. There is no room for less than stellar surgical technique.  Even with best techniques, some slight asymmetry post rhinoplasty is inevitable. 
  • Temporalis fascia or Alloderm may be added beneath the thin skin as a small “camouflage blanket” to create smoother post-op results.
  • Tip grafts are usually avoided in thin skinned Rhinoplasty patients to avoid edges from showing during healing.
  • Open Rhinoplasty technique or closed delivery Rhinoplasty techniques are often used in patients with thin skin.
  • Very beautiful results are achievable in Rhinoplasty patients with thin skin when the proper Rhinoplasty techniques are used.
  • Typically Rhinoplasty patients with very thin skin tend to be of northern European decent or Caucasian.

  1. Patient of Dr. Naderi who had an original Rhinoplasty many years ago by another surgeon resulting in contour irregularities and harsh shrink wrapping of her thin skin to the underlying cartilage and bone.  Dr. Naderi did her Revision Rhinoplasty and reconstructed the nasal cartilages then used Alloderm to “soften” the appearance of her skin for a more pleasant nose.

THICK SKIN RHINOPLASTY:

  • Minute or average “bread and butter” nose job surgical maneuvers may not show as significant visible changes in thick-skinned patients.
  • Rhinoplasty patients with thick skin have a significant subcutaneous fatty layer beneath the skin and this layer can hold swelling fluids (edema) for a very long time.
  • Rhinoplasty patients with thick skin can develop post-op scar tissue beneath the skin as the post-op edema lifts and creates a “potential space” under the skin and above the cartilages and bone. This “space” can fill with scar tissue. Post-operative steroid injections are usually indicated in Rhinoplasty patients with thick skin to prevent soft tissue polly beaks.
  • An experienced Rhinoplasty Specialist may very gently thin this subcutaneous layer out to slightly think the skin in a thick sebaceous skinned patient. However, extreme caution must be used to avoid compromising the blood flow to the skin in order to prevent skin necrosis. This is a very advanced technique that must be used conservatively. Some plastic surgeons, outside of the United States, use pre-operative Accutane to thin the skin. However, the risks of Accutane are too high to be justifiable for elective surgery and I do not recommend this risky medication for this purpose.
  • “Structural Rhinoplasty” techniques with the use of sutures and cartilage grafts must often be used in Rhinoplasty patients with thick skin. (Think back to the camping and tent analogy: a strong tent pole must be used to create a nice defined tent.) In Rhinoplasty patients with thick skin, additional cartilage in the form of grafts are often used to create the definition and narrowing desired at the tip and along the bridge. This may be a counterintuitive concept at first for patients (and unfortunately for many inexperienced Plastic Surgeons). While in Rhinoplasty patients with thin skin, cartilage and bone is removed to create more definition and refinement, in Rhinoplasty patients with thick skin, cartilage is added to create the desired definition and refinement. Removal of excess cartilage in Rhinoplasty patients with thick skin will create a “potential space” which can fill with scar tissue. Scar tissue has no definition and appears as an amorphous blob making the nose worse that prior to Rhinoplasty!
  • Sutures can also be used to bend and reshape the cartilages in Rhinoplasty patients with thick skin into a more desirable shape without removal of cartilage.
  • Often Rhinoplasty patients with thick skin also have very weak cartilages. This is an unfavorable situation that will not lend to nice aesthetic Rhinoplasty results unless additional adequate structural graft material is harvested from the septum, ears or ribs. I do not advocate the use of “man made” or artificial implant materials due to a high risk of infection and extrusion.
  • Very beautiful results are achievable in Rhinoplasty patients with thick skin when the proper Rhinoplasty techniques are used.
  • Open Rhinoplasty technique or closed-delivery Rhinoplasty techniques are often used in patients with thick skin.
  • Typically Rhinoplasty patients with thick skin tend to be of African, South East Asian or Hispanic decent.

  1. Patient of Dr. Naderi with thick oily skin and a heavy ptotic droopy tip who underwent primary male Rhinoplasty with tip grafts to create a very nice natural looking masculine nose.