Does having thick skin mean I can NEVER have a refined nose tip?

I have patients from many ethnic backgrounds who see me for rhinoplasty.  Thick skinned individuals is common in my practice.  You can certainly thin the skin by conservatively removing fat beneath the skin in the nasal tip.  You can also place grafts that will help define the nasal tip as thick skinned individuals frequently have weaker tip cartilage and the grafts help to define and support the tip. With all of that said, it is also important for your rhinoplasty surgeon to set realistic expectations with you.  Attempting to thin and define a tip more than nature will allow can result in significant complications and deformity of your nose.  

It is a multifactorial approach:-defat to the fullest the domes of the alar cartilages, even denuding them from the perichondrium-total removal of the interdomal fibrofatty pad-very cautious and meticulous removal of the subcutanous subdermal fat of the tip-overcorrect the size, sharpness and prominence of the, clearly indicated, tip Sheen's grafting, using very strong and firm cartilage (likely from the septum insteand the commonly recommended ear one)-may the tip support be weak or not very firm then tip support maneuvers (strut or others) are required to make the overcorrected tip graft arise to the surface the define the tipAll this is due to the thick sking hiding partially or subtotally any tip definition maneuvers built underneath.In a very skinny tip the approach would be the opposite:-leave the domal cartilages with their cover, and in some exceptionally skinny transparent tips I have had to add temporal fascial or spared dorsal hump perichondrium graft to cover the domes as a camouflage blanket-make the minimal and essential fibrofatty pad removal-no touch to the skin, hadle with care-undercorrect and carefully size and shape any tip grafting or tip plasties, carrying out intraop testing of tip domes / grafting visibility or naturalness, using (if indicated) soft and pliable grafting, or even scoring it in a grid unicortically to weaken it-avoid adding unncessary or non-essential tip supportAnd any intermediate scenario between very thick and very thin skinned tips has to be finally assessed intraoperatively until naturalness is balanced with visibility of the tip definition maneuvers, taking any actions suitable to achieve such harmony; it is as bad a lack of as an excess of tip definition.

Naturally thick skin tissue covering the nasal framework can play a frustrating role in limiting the more subtle refinements possible. But some very nice changes can still be achieved, and there are some special techniques (eg. cartilage grafts) that are often used to help with this situation. Unfortunately, the skin cannot be thinned - a layer of scar tissue would result that could be as thick (or even thicker!) than was originally present.