Is my tip too amorphous/thick skinned for a rhinoplasty? (Photos)

Question

I've read a lot that I am not likely to see a lot of improvement from a rhinoplasty if I have thick skin. I'd like to fix my overprojection / large tip. Is this possible? What type of procedure will give me a refined tip?

Alejandro Nogueira, MD · Answer

These African, Afroamerican or Afrocaribbean ethnic noses may present different genetical issues the patients might wish to modify, among which worth mentioning thick skin, low dorsum, broad dorsum, flat dorsum, broad nose, short nose, short septum, short tip, bulbous tip, poorly defined tip, large nostrils, large sills, alar flare, poorly supported tip, overrotated tip, alar rim retraction, etc.
Its treatment is based on the principles of structure rhinoplasty although upgraded and extended to a higher and larger level of complexity and technical options, with massive cartilage supply from nasal septum, ears concha and very often from rib cartilages, to restore the enormous lack of support, the weakness and the underdevelopment of the nasal skeleton.
Your case allows understanding the majority of anatomical features and technical requirements of such ethnic rhinoplasties, keeping in mind that great part of their features are common to other ethnicities like the Asian, Philippine, etc; the underlying skeletal peculiarities cause the characteristic shape in this ethnicity noses and are the reasons behind their very high surgical difficulty, which explains why there are very few surgeons really trained, capacitated and skilled in such ethnic rhinoplasties and why most surgeons are tempted to employ simpler but disappointing, when not failed or even problematic, resolution methods.
Three key aspects feature African noses; the barely existent dorsum and the truncated nasal pyramid, from which half or more is missing; the totally collapsed nasal tip which lacks any kind of support due to totally incompetent filmy alar cartilages, tip which is also disproportionately augmented by a huge fibrofatty pad; and the large nostrils and excessively protruding alar flare.
The first stage after the open approach dissection of the nose is defatting the massive pad which typically makes these noses bulbous and large; this adipose mass is not only located above and in between the alar cartilage domes, like in any other ethnicity, but also extends between the medial cruras of the columella and spreads over the lateral cruras, the supratip dorsum and the sides of the lower nasal wall; a very meticulous defatting is a must, a very delicate maneuver that must be carried out with great care not to damage the cartilaginous structures and the overlying skin.
Another common finding is how weak, filmy and thin are the alar cartilages in this ethnicity, they play almost no structural role, if any, in the tip and alae shape, being the whole tip unsupported, collapsed and its shape made out of the fibrofatty mass and the skin itself; additionally the tip has no definition is too short and its cartilages lack sufficient length to comply with the required lengthening of the tip and the nose; for all these reasons the lateral cruras are frequently discarded and replaced by new ones made out of the cartilage rib grafts.
The tip and the columella also needed full replacement, therefore an en bloc tip and columella extended graft can be sculpted out from the rib cartilage grafting; a slot is tailored at the rear side of the columellar part of it so that this graft could be interlocked with the septum inserted in it; a cubic chip is removed at its top so that the dorsal reconstruction and augmentation graft can be inserted and interlocked into this space.
Therefore this is a dorsocolumellar replacement graft augmented with one extension to build the tip and another extension to lengthen the columellar support down to the nasal septum; this structure achieves longitudinal and lateral blockage with stability by pressure forces between the radix, the dorsum, the septum and the interlocking between the dorsal and tip columella parts, with lateral assistance at the tip by means of the side pods formed by the new lateral cruras; no suturing is required to achieve stability of this dorsocolumellar structure.
In the end, the whole dorsum, tip, columella, medial cruras and lateral cruras are replaced by handmade brand new anatomical elements.
It is remarkable how the septum is also massively short in these ethnicities; this makes the septum insufficient as donor of grafting in most cases and technically forces to some kind of septal lengthening and nose lengthening maneuvers; this is accomplished by the dorsocolumellar structure which bridged over the missing gap of septum; no need for direct septal lengthening grafting.
Several methods allow rebuilding a massively missing nasal dorsum, either by congenital causes like ethnicity or by acquired traumatisms or iatrogenic dorsal over resections during previous rhinoplasties.
The alloplastic or synthetic prosthesis, made from Gore Tex, Medpor, Silastic, silicone, polyurethane, etc., is a tempting option since it is as easy as an out of the box solution, the surgeon only has to open the sterile sealed package and insert into the nose, only in few cases a slight shaving may be necessary to adapt the prosthetic dorsum to the patient's nose; however this is the worst of all the available technical solutions, to begin with it is unfeasible achieving an optimal fitting on the dorsum, the prosthesis is noticeable through the skin, they look pretty fake and unnatural, the rate of complications like infections, displacement or extrusion are terribly high, they are prone to dislocate, develop capsular contracture, extrude or become secondarily infected during their lifetime, which actually is not indefinite and will need replacement after a few years.
Fat transfer and dermal or fascial rolls are not suitable, they lack volume to rebuild such noses, their look is weird, it is impossible to shape the dorsum with precision and they are not consistent enough; apart from the former they are prone to complications, infection and resorption; they'll likely disappear in the postoperative or be short lasting.
Bone grafting is not recommended, the rates of resorption are very high and the look is not natural; the ideal material to rebuild massive dorsal shortfalls is cartilage grafting, being several the modalities.
Irradiated human or animal cartilage from a tissue bank is not a recommended option; firstly because it is not own patient's tissue, making no sense when there are excellent donors sites available of safer quality, however mainly because the rates of resorption, infection and dislocation with deformities are very high with irradiated cartilage, which in practical terms is a cartilage biologically destroyed by radiation.
Ear and septum cartilage harvested from the patient's tissues are excellent donors biologically but in the vast majority of cases not valid because the available amount is scarce or their shape might not be optimal; notwithstanding their use may be suitable in selected cases.
One popular option which deserves severe criticism is the so called Turkish Delight technique or better named as diced cartilage wrapped in fascia; it essentially consists in harvesting cartilage from the patient's donor sites, commonly the rib, and crush down to tiny bits, which means destroying the chondrocytes or cartilage cells and annihilating any biological viability; once this jelly mass is obtained the surgeon sticks the bits together by applying a synthetic fibrin glue, rolling them in temporalis fascia or both; this roll is inserted as neo dorsum, however the result is an avascular cylinder in which this mass of crushed tissue develops necrosis, resorption, eventually infection, irregularities, deformities, cystic phenomena, etc.; the results are between poor and disastrous in the mid and long term, the touch is fake like jelly and the dorsum experiences molding like it would be clay with palpation or bearing the glasses pads.
The ideal option to massively rebuild nasal dorsums is own patient's rib cartilage; in relative terms to the nose size it is an unlimited source of cartilage, it is biologically compatible and safe since it belongs to the patient, the likeliness o resorption, infection and displacement are terribly low, is firm and strong enough to expand the skin, is form stable, the touch and feel is natural, when it is well tailored the look is totally natural, it should be lifetime lasting and totally opposite to what many surgeons think it does not warp; the only caution to be taken is harvesting straight fragments of rib cartilage and not the curvy ones, and as additional caution peel off the cortex and use mainly the core or central shaft of the cartilage, since the cortex or outer layers have curvaceous streaks of cartilage making it prone to warp.
In the case you post here the rib cartilage not only is an excellent option to rebuild the dorsum but also may serve as donor for other grafts required, like the tip and columella replacement graft and the lateral cruras replacement grafts; the septum, otherwise very short, and the ears remained untouched.
Once the rib cartilage is freed and the donor site meticulously closed by means of layered sutures, the sculpting stage starts so that the necessary anatomical elements can be restored in this kind of noses.
With the personal design I follow in these cases images, one single fragment of cartilage is shaped as dorsal rebuild graft with a hollow cylinder carved in at the undersurface of such dorsal graft; this cylinder has the purpose of providing stability by blockage obtained when the patient's natural dorsum would be inserted within; this dorsal graft has other very tricky and interesting geometrical features in its design, like the beveled upper end to match the contour of the nasal radix and the frontalis bone at the frontonasal sulcus, the slope gradient at its lower end to prevent a supratip prominence or polly beak deformity, the somehow imperfect broken contour at its sides in a very slightly rhomboid shape to mimic a natural bridge and avoid a plasticized nasal look, and the thin on top towards thick on bottom of dorsum gradient of dorsal raise in order to create a correct nasal profile; at its caudal end this dorsal graft is shaped featuring a cubic prong matching the tip and columella extended graft in order to achieve interlocking stability by perfect pressure effect.
Once the dorsocolumellar grafting structure is thoroughly tested and deemed as definitive in terms of aesthetic effect and mechanical stability, the final closure of the skin allows the assessment and planning of the nostril sills resection and the alar flare wedge reduction.
The smooth contour and the perfection of the tailoring of the dorsal block makes unnecessary additional camouflage with temporalis fascia or specific blockage gestures to prevent its displacement, since the final assembly is a perfect puzzle matching under pressure between the frontalis bone, the original dorsum and the caudal septum.
Experience, fine skills and large amounts of creativity are of paramount importance in order to successfully approach these complex rib cartilage ethnic rhinoplasties.
See the link below to view a full series of images explaining the procedure with real intraoperative and before & after photos.
If you wish better grounded opinion well lit, focused and standard images have to be assessed: frontal, both lateral and both oblique views, from underneath too.
Feel free to request any additional information from me.

Rady Rahban, MD, FACS · Answer

While thick skin is a limiting factor when it comes to rhinoplasty, it does not mean that you cannot improve the shape and cosmetic appearance of your nose.  A consultation with a board certified plastic surgeon, who specializes in rhinoplasty, and has experience in ethnic rhinoplasty, will help you better understand what a realistic end result is for you based on what you are starting with.

Philip J. Miller, MD, FACS · Answer

The most common things addressed by my African American patients in regards to their nasal shape are:
Weak or thin cartilage in the tip of the noseThick skin on the noseA low nasal bridgeWide nostrilsThe most important thing you can do on your journey toward finding the right surgeon is to seek out a board certified facial plastic surgeon that specializes in ethnic rhinoplasty. You want to put your nose in the hands of experience and have a unified vision with your surgeon. Cost will vary due to facilities fee, anesthesia fees, etc. 
I hope you find this information helpful as you move forward. 
Sincerely,
Philip J. Miller, MD, FACS

Gerald Minniti, MD, FACS · Answer

Hello,Although your skin is thick, it is clear that your tip shape and size is also dictated by cartilage, which can be predictably modified. For someone with thick skin, an open structural rhinoplasty is key to achieve long term good results. Go visit a few ABPS certified/ASAPS member surgeons (or AAFPRS equivalent) who specialize in rhinoplasty. Best of luck!

Stephen E. Metzinger, MD · Answer

Dear looking4answers22: Thank you for your questions and photographs. While skin thickness does limit the amount of definition that can be achieved with a rhinoplasty, significant improvement can still be accomplished. I recommend that you see a board-certified plastic surgeon or facial plastic surgeon with rhinoplasty experience for an in-person consultation to discuss the surgery in detail. When choosing your surgeon, be sure that he or she is experienced in ethnic rhinoplasty. The Rhinoplasty Society is a good place to start. Good luck and I hope this helps!

Eric W. Cerrati, MD · Answer

While the thickness of the skin does limit the amount of definition that can be achieved with a rhinoplasty, a significant improvement can still be accomplished.  I recommend that you see a rhinoplasty surgeon for an in-person consultation to discuss the surgery in detail.  When choosing your surgeon, be sure that he or she is experienced in ethnic rhinoplasty.  There are classic findings that can be addressed to provide the most optimal result.

Javier Soto, MD · Answer

Hello and thanks a lot for sharing your question with us,definetly the rinoplasty is the reccomended procedure for you,it will help you to improve the projection of the tip and to get a more slim and fine nose ,as we can see in the pictures that you share the nasal wings are to wide,thats why it looks like that,with the rinoplasty you can get the results you are expecting,i reccomned you to do a research of a board cerificate plastic surgeon and post op services .

Thanks a lot ¡

Thanks a lot ¡

Alexander Ovchinsky, MD · Answer

Your nasal anatomy is very typical for an ethnic nose, i. e. low set dorsum, widened tip with thick skin and wide alar base. All these issues are typically encountered and corrected during ethnic rhinoplasty. Even though your tip refinement result may be somewhat limited due to the skin thickness, you should still see a good amount of improvement postop.

Robert E. Zaworski, MD (retired) · Answer

While thick skin can present a challenge, you can still expect improvement from Rhinoplasty surgery.  Personally, I enjoy doing ethnic noses as the results can be remarkable.  Consult with board certified Rhinoplasty surgeons for an in person evaluation.

Richard W. Fleming, MD (retired) · Answer

Thick skin does limit the amount if tip refinement that can be achieved but you can significantly improve the appearance of your nose. A more balanced proportional result would give you a softer more feminine appearance.

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