What Happens to the Excess Skin After a Rhinoplasty and What Does the Squishy Nose Mean?

That is one of the most astute questions I've seen on RealSelf! In fact, I am a Fellowship Director and I often pose this very question to my Fellows and Residents and they often seem dumbfounded. Skin is almost never removed when performing a rhinoplasty, even if the nose is made much smaller. In order to address this I think it is vital to widely undermine the skin (separate it from the underlying structure) in an area greater than just that which is being modified. By doing so the redundant tissue will have a greater surface area to allow for redistribution.  As the wound contracts with normal healing, the skin will redrape evenly. This process of wound contraction seems to be better for younger patients and, as expected, older skin is less elastic and therefore less likely to shrink. If only limited undermining is performed, then the areas where the nose was reduced will now have 'extra' skin on them and they won't have anywhere to flatten out...so over time the dead space that is beneath those areas becomes filled with scar tissue.

Other than wide undermining it is a good practice to avoid over reducing a nose. It is a much better concept to change the shape and redistribute where that soft tissue will need to go rather than to drastically make it smaller. In the event that a nose is over reduced there is often lots of scar tissue and mushiness with a lack of definition...something to be avoided at all costs.

The 'Squishiness' in your tip might be due to the strength and shape of your underlying cartilages. If I were to operate on someone like you I would probably try to strengthen those to provide for more definition.

Dear higuys,

Thank you for your question.  Photos usually help in explanations.  In general, the skin is elastic.  It will retract to the dimensions of the underlying structures, within reason.  This is why you can make a large nose, smaller, but not necessarily small.  Squishiness I assume is related to poor support structures (caritlage) of the tip.  A strut can be made of firmer cartilage and placed at the tip to strengthen it.

Best wishes,

Pablo Prichard, MD 

 When performing a rhinoplasty there is no skin excision. The undermining of the skin and bridge line and tip  are accomplished in such a fashion that the skin re-drapes over the cartilaginous framework.  The skin shrink wraps over the new framework of the tip. In thick skin individuals  the skin does not shrink-wrap as well as thin skin individuals. Sometimes cortisone shots are required to reduce edema that is present in the supratip area of the nose in the postoperative phase.  For many before and after examples of closed rhinoplasty, please see the link and the video below

Dear patient,

Thanks for your inquiries.
In your case, we call it ‘long nose’ or ‘plunging tip.’
You don’t need to remove the excess skin, but it seems your alar cartilages should be rotated upward. Diverse methods of cartilage rotation can be applied according to each person’s nose shape and status.

Thanks,

Dr. Kwon Take Keun

Nasal skin is not removed during rhinoplasty. After modifying the structure of the nose, the nasal skin will contract or "shrink wrap" around the underlying skeleton of the nose. Stephen Weber MD, FACS

The refinement that is achieved in the nasal tip in rhinplasty is highly influenced by the overlying skin's ability to shrink. As long as the amount of tip skin is not excessive (medium thickness description suggests it is not excessive), you should have good skin shrinkage that largely reflects the underlying cartilage reduction. Nasal skin is never cut out.

A rhinoplasty surgery involves the reshaping of the underlying cartilage and bone of the nose.  Much like a tent we can alter the poles but the canvas of the tent has to shrink down over the altered structures. If the skin of your nose is very thick it will not shrink as readily as a person with thinner skin.  There is nothing that can be done about this as skin is never resected except to narrow a wide nostril base. 

Sounds like you have thick skin that sometimes does not contract enough to give the very refined look that is ideal after rhinoplasty.  That said, you should have an improvement  with reduction of the underlying cartilage tissue.   Donald R. Nunn MD  Atlanta Plastic Surgeon.