These are of course more challenging cases than
typical- and in most of these cases, the key element to achieving the
kind of results you desire is in establishing proper tip support. Most
commonly tip support in cases like yours is achieved with the tongue-in-groove
approach- a structural approach that permits significant tip support from
which the rest of the tip can be sculpted. Refining a nose is much more than
removing cartilage- in fact the goal in most cases is to preserve most
cartilage but making it most aesthetic through sculpting techniques.
Defatting of skin is not always needed. Several techniques exist for
nostril reducing, which I consider the “icing on the cake” in a case like yours
to refine the rest of the results.
The tip can be refined and the bridge and nostrils narrowed through a closed rhinoplasty approach to produce a natural result.
Find a board certified plastic surgeon who performs hundreds
of rhinoplasties and rhinoplasty revisions each year. Then look at the
plastic surgeon's website before and after photo galleries to get a
sense of who can deliver the results.
Kenneth Hughes, MD
Los Angeles, CA
Without pictures, it is impossible to give any advice on what may or may not need to be accomplished with the rhinoplasty procedure. In general, the bulbous tip is addressed with suture techniques to the lower lateral cartilages and sometimes a conservative cartilage removal if they are excessively wide. The nose can be de- projected by shaving down the dorsal hump which is usually cartilaginous in nature. The width of the nose is narrowed with medial and lateral osteotomies to the nasal bones. The nostril reduction is accomplished with an alar-plasty procedure.
Given your history, it is impossible to give you advice without seeing you or seeing photos of you. Yes, a bulbous tip can be reduced; yes, a wide bridge can be refined; and the projection can be worked on. It sounds as though you have thick skin which may require intervention post-rhinoplasty.