Why Does Skin Thickness Matter for Nose Surgery?

Skin quality and thickness is one of the most important factors in determining your final Rhinoplasty result. And it can also be one of the hardest to predict.

When we perform Rhinoplasty, most of what we do involves altering the cartilage and bone that makes up the nasal skeleton. We shape the cartilage and bone in many ways to take on the new desired contour. During the healing period for many months after surgery, the skin and soft tissue that lays over this skeleton must contract inwards and ’shrink wrap’ onto this altered framework for the desired changes to become noticeable. That’s why you don’t see real definition for weeks to months after surgery while the skin and soft tissue is swollen.

Most people have skin of moderate thickness. The thinner your skin, the faster and better it will contract. So, if you have very thin skin, you can expect over time that a lot of definition can be achieved. This has obvious advantages but may also have its disadvantages.

Thinner Skin:

Thin skin will allow for a high degree of refinement but any tiny irregularities or asymmetries may also show through. This can be especially true if you have thin skin and very strong prominent cartilage underneath. You can recognize this in someone whose entire tip cartilage outline can be seen easily through the skin.

We may recommend in certain circumstances using a layer of material, such as fascia or acellular dermis (Alloderm), during surgery as a thin cover and concealer to help smooth out your final look.

Thicker skin:

At the other extreme is very thick skin. Thick skin readily conceals any tiny irregularities. However, it can be much more difficult to achieve the desired level of definition and refinement because sharp lines and angles can appear blunted under a thick cover. Sometimes it is just not possible in this scenario to achieve very sharply defined features. There are some things we can do to improve definition, though.

If your skin is very thick and you want increased definition, we may use larger tip grafts or dorsal grafts (on the bridge) to compensate. We may also judiciously thin out the fatty tissue under the skin, especially at the tip, to achieve more refinement.

Another potential pitfall occurs when a thick-skinned nose must be reduced significantly in size. Thick skin tends not to contract as much or as quickly as we might like after surgery. If the nasal tip or bridge is reduced too much, the space in between the reduced nasal skeleton and the skin can fill in with scar tissue over time. The result can be a nose that may be somewhat smaller, but is amorphous in shape and poorly supported. It tends to look a little ‘blobby’ once healed and patients often end up unhappy because they wanted a small, refined nose instead of a small, unrefined one.

To avoid this outcome, we will usually recommend reducing your nose a little more conservatively in this situation. Thick skin requires more support, so leaving a strong nasal framework is an especially good idea in this setting. A very nice and dramatic result can still be had and a moderately smaller, but refined, nose will tend to look much better for you. Sometimes we can push along the skin shrinkage with steroid injection and having you place tape over your skin at night for an extended period after surgery to achieve the optimal result.

It’s important to keep in mind also that thicker-skinned patients will usually take longer to see the degree of refinement they want, sometimes up to 2 years or more after surgery.

Bottom line:

The good news is that an experienced rhinoplasty surgeon can get a good sense of your skin type, thickness, and quality during your assessment, and give you a very good idea of what results can be expected or achieved. Your skin thickness should also be taken into account during surgery when changes to your nasal framework are made. This will render post-operative healing more predictable.

If you have particular questions related to your skin thickness, feel free to post them and we’ll get back to you as soon as possible.

Skin thickness is important because it can adversely affect the final result of your nose surgery, if not taken into account by your surgeon. The skin of the nose varies in thickness from the bridge, where it is generally thin, to the tip and nostrils, where it can become thicker. Some ethnicities tend to have thicker skin on the nose than others.

Thick skin can limit the amount of narrowing or refinement one can obtain in the tip of the nose. On the other hand, it can also disguise slight asymmetries in the underlying cartilage and bone framework of the nose. Thick skin can be made thinner by adding more projection to the nose (the way the lining of a balloon thins as it is inflated) or by carefully removing fat from underneath the skin.

Thin skin allows a more refined nasal tip, however, irregularities or asymmetries in the underlying framework can become more visible over time. Thin skin can be thickened by placing soft tissue grafts underneath the thin portion of skin.

Remember, however, these techniques to thin or thicken the skin only work to a limited extent.

The way that I describe the effect of skin thickness on rhinoplasty results is to use the analogy of a down comforter versus a fine Egyption cotton sheet. A thick comforter lying over an object makes it difficult to see the shape of the object while a thin sheet allows one to see every edge and contour.

The underlying cartilage and bony structure of the nose will show through easily in thin-skinned patients which allows for increased refinement of the nose. However, it is critical to make sure that there are no prominent edges or grafts as these may show through the skin over time as the swelling resolves. In these cases, I often place a soft tissue graft (such as temporalis fascia) to camouflage grafts at the tip, for example.

In thicker skinned patients, there may be limitations in the degree to which the nose can be narrowed and refined. The skin envelope can be carefully thinned to a certain extent, however, the key in these cases is to create a prominent and strong underlying framework. 

During your consultation, an experienced rhinoplasty surgeon should be able to assess your skin thickness and explain its impact on your surgical outcome. 

In most Rhinoplasty, the surgeon reshapes the nose by reshaping the skeleton of cartilage and bone.

This framework of support for the nose shapes the overlying nasal skin.

Imagine covering a chair with a fine silk cloth: you'll see every angle f the chair and easily discern it's shape.

Now cover the chair with a rug: the result is amount that may not even look like a chair.

In this analogy, thin skin is like the silk cloth and thick skin is like the rug.

How the skin drapes over the framework determines how much detail and angularity or refinement your surgeon can "carve" into your nose.

 I have performed Rhinoplasty for over 20 years and this is a great question.  The thicker, the nasal skin, the less a sculpted tip underneath this thick skin can show through.  Thin skin shows every detail of a sculted, thin tip that's created during Rhinoplasty while thick skin will not.  The subcutaneous tissues can be thinned  but there's another difficult aspect of thick, especially thick and oily skin.  This type of skin has a tendency to create additional scar tissue above the undelying sculpted cartilage that, once again, diminishes the external appearance.

Overlying nasal skin quality and thickness are probably the most important fact that patient and surgeon must carefully evaluate prior to surgery. Both "limit" situations (too thin or too thick skin and soft tissue layer) are not good when planning a rhinoplasty (they affect adversely). So definitely this fact will affect the results of a rhinoplasty surgery. Obviously it will depend on the amount of cartilaginous and bone structures planned to be altered (removed) during the nose surgery.

Thicker skin hides contours and redrapes differently over the fine cartilage structure that are sculpted at the time of Rhinoplasty. I use this analogy with my patients: 

In the summer, you sleep with a single sheet on your bed, which when covering your feet, shows the outlines of all of your toes and you can see and count them all. (Thin skin, sculpted, defined anatomy)

In the winter, when it is cold, you sleep with a thicker comforter to keep you warm, which when draped over your feet reveals your feet, but you really cannot see each toe like you can the single sheet. (Thick skin, less fine detail and definition).

Hope this brief description and analogy helps!

Dr. C

The type and thickness of a patient's skin can have a big impact on the rhinoplasty results. For thick-skinned patients, the postoperative swelling can be more pronounced and can persist longer. Additionally, with very thick skin, the tip may not be as refined appearing. Thin-skinned patients run the risk of have visible irregularity of the tip cartilages (if they are modified).

Your question is a common one.  without images it is not possible to address your personal concerns, however in general terms an individual with a thick skin envelope may not see as readily the changes in shape created.  This is particularly seen in the tip area.

Best wishes,

Sergio P. Maggi, MD, FACS

Austin Plastic Surgery Center

drmaggi.com