Patients who have thick nasal skin can have Rhinoplasty to improve the shape of their nose but they should understand that there are limitations. Doing Rhinoplasty in oily, thick, bulbous nose is a challenge to any Rhinoplasty surgeon. Patients always come with unrealistic expectation which should be discouraged. The way a Rhinoplasty is performed is that the skin is raised off the bony-cartilaginous framework of the nose and the frame work is reshaped to give the desired external nasal appearance. In ethnic type noses where the thicker skin requires a different approach.
Defatting the nose during Rhinoplasty
Any changes to the under surface- the tip cartilage and bone is not as visible as it is obscured by the thicker skin. The significance to the thickness of the soft tissue enveloping the nose, in particular the skin and fatty layer is that it is more difficult to refine these types of noses.
Removing sub dermal fat and subcutaneous tissue must be done with care. This gives a narrow profile with sharp tip. The nasal skin is very delicate with critical blood supply.
However, for the nose to look good, the skin needs to fit tightly around the newly shaped framework. Because thick skin has flexibility and elasticity as thinner skin, it will not drape as well or fit as tight.
Cartilage grafts are harvested from septum and used because adding cartilage can help define the tip in patients with thick skin. Tip grafts and using sutures to bend the cartilages are more important then removing cartilage but other factors such as dissecting in the proper plane to avoid damaging the muscle and skin and creating more scar tissue is very important as well. Aggressive defatting can result in skin necrosis or loss of tissue and a very poor result
When we talk about defatting, it is a combination of removing some of the transverse nasalis muscle over the bridge of the nose and some of the fibro-fatty tissue over the nasal tip.
To get a narrow the tip or profile one can sew the cartilages together to create a more narrowed tip often in conjunction with cartilage grafts.
The type of thick skin nose that can be helped the most is one with a wide tip and decreased tip projection. By increasing the tip projection, tension is placed on the very tip causing it to get thinner and the flared side walls tend to straighten. Also, some of the bulk of the fat side walls where the walls meet the cheeks can be removed by taking out an alar wedge of tissue in that area and hiding the scar in the nose-cheek crease. This will make the nose look narrower and less bulky.
It is somewhat possible to thin out thick skin on a Rhinoplasty; however, the scar tissue can grow back. People who have thick, oily, olive skin tend to develop sub dermal keloids, hypertrophic scarring, and fluid retention in the supratip area of the nose. To help bring down the fluid retention, multiple cortisone injections during in the first three months in the postoperative phase may be necessary.
