Bulbous Tip Hard to Refine if I Have Thick Skin? (photo)

There are several things that surgeons can do to define a nose with thick skin. First the tip needs strong support. Columellar strut grafts or a tongue and groove technique is used for this purpose. The tip cartilages are then defined and narrowed using dome sutures. Additionally, cap or tip grafts may be used to "push " the tip through the skin. The last and final step is the thinning of the nasal skin from the inside. 

Trimming the upper edge of the tip cartilages will give you most of what you want. If you want a more Romanesque tip with very defined light reflecting points the cartilage grafts placed to achieve that will be less effective because of the tissue thickness. The key question is how much refining you want or will settle for given the limits of thicker soft tissue.

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The key with these thick skin cases is strengthening the nose-  helping to project the tip and define it as well as possible.  In addition, I find post operative injections of steroids help the skin to reduce its thickness.  One advantage of thick skin-  it helps conceals any small imperfections.

     The level of refinement can be impaired to some extent with a thicker skin envelope, but the underlying lower lateral cartilages can be reduced in size and brought into a more favorable conformation.  In this way the tip can be refined.  The envelope can be manipulated as well, but the thickness of the skin will have an impact.  Nonetheless, you could have a very noticeable improvement with a closed rhinoplasty.  Kenneth Hughes, MD Los Angeles, CA

Refining a bulbous tip involves reshaping the underlying cartilage and possibly bone to create the changes desired.  The issue with thick skin is that it will camouflage these changes and reduce how they impact the external appearance of your nose.  Techniques such as conservative skin thinning during surgery or post-operative steroid injections when needed can improve final results.  Also note that patients with thicker skin tend to experience more swelling after surgery which will take longer to resolve.  Discuss these issues with your rhinoplasty surgeon so they can advise you on what expected results can be achieved.  Hope this is helpful!

The tip cartilages can be narrowed and refined regardless of skin thickness. The issue is that the delicate cartilage framework and surgical refinement can be less apparent in someone with thick skin as the soft tissue overlying the delicate tip structure obscures the underlying framework. This can typically be dealt with following surgery with steroid injections of the soft tissue envelope. I hope this information is helpful.Stephen Weber MD, FACSWeber Facial Plastic Surgery

 Thick skin and a bulbous tip can be a difficult problem to deal with in the healing process. The surgical technique involves narrowing the tip cartilages with sutures and removal of portion of the tip cartilages as well. Thick skin  patients will receive several cortisone shots in the supratip area of the nose in the first few months  during the postoperative period. It's best to have realistic expectations when performing the  rhinoplasty surgery. Please see  the link below for results of bulbous tip rhinoplasty in our practice.

In patients with thick nasal tip skin, I minimized the cartilaginous tip width during surgery and tell my patients at 6 weeks I may have to inject steroid subcutaneously into the scar to minimize the the scaring and maximizing the narrowness of the nasal tip.

Hi,

There are several ways of tackling a bulbous tip. It depends what is causing the bulbosity. There are bulbous tips caused by overdeveloped lower lateral cartilages, fatty tissue under the tip and weak supporting cartlilages, as well as bulbous tips caused by scar tissue.

See video links that show how these procedures are done.

Best,

Dr.S.

Your bulbous tip can be narrowed to achieve better definition. We can change the size, contour, and strength of the tip cartilages but we cannot change the overlying envelope of skin. Achieving the results you want depends on your expectations. Consult with a rhinoplasty specialist who will show you results in similar patients and establish reasonable goals.