Generally, the outcome of nasal surgery in the hands of the most skilled surgeons still depends on two main factors:
- The type of patient’s skin in terms of flexibility, thickness and the elasticity
- The beauty of the rest of the face
Regarding the skin texture, I usually use an example for my patients that is very helpful in understanding the issue, which is the difference between a leather ball and a balloon. Due to having elasticity, a balloon reduces its size by decreasing the air within without losing its form, while a leather ball size will reduce slightly while the air within decrease, and a certain excessive reduced volume would cause its deformation.
However, no skin elasticity is either low-elastic like a leather ball or has a very high elasticity like a balloon. But, this example helps the patients to understand why two different skin reactions are quite different. Nose consists of three major layers:
- Skin and the muscles affixed to underneath
- Nasal bone – cartilage structure or skeleton that is more made of bone at the top and more cartilage at the bottom
- Nasal internal lining or mucous, which covers the nose from inside
In rhinoplasty, skin and its clung muscle layer are lifted from the cartilage and bone layer, and the changes in the cartilages and bones are made. In some points, reduction and sometimes increase and mostly transformation in cartilages and bones are made. Almost nothing is done in the skin layer and muscle, and this layer reacts to changes made in bones and cartilages based on its elasticity. It lies on cartilage and bone layer and gradually acquires the desired form. Here, the skin elasticity determines how much the surgery can be effective. Highly inelastic skin or the so-called fleshy nose hardly responds volume reduction, while it respond relatively good to form change and will respond well to increased volume. Therefore, in case of fleshy noses, if much volume reduction is not to be done, a good surgeon can get very good results.
However, a good, supple and young skin with good elastic properties (or the so-called bony nose), provides an excellent maneuverability for a good surgeon to do different changes. Although even a less experienced surgeon can get modest results in bony noses, but performing surgery on fleshy noses surely needs an accurate and fully-experienced surgeon. After all, even in the hands of a good surgeon, a nose with a good skin (bony nose) would gain a better result than a nose with bad skin (fleshy nose).
The second factor affecting the operation outcome is the beauty rate of the rest of the face. In a beautiful face, even a moderate result in the nose surgery will be satisfying, while an individual that the rest of his/her face is not beautiful will be sensitive to the smallest details after nasal surgery. A person with a small chin or dimple cheeks or who has a long lip back and narrow lips redness, the nose has a protruding nose and reveals projected, which even with a good nose (in case of not correcting the rest of face problems), the nose appears partially protruding. Thus, the small size of the rest of the face components make the nose appears bigger. Sometimes the correction of chin, cheeks and even the lips may indirectly cause the nose looking smaller and more beautiful.
What do we mean by bony and fleshy noses?
As explained earlier, the nose is composed of three main layers:
- Outer lining layer that is composed of skin and a fine muscular layer attached to its underside surface.
- Bony-cartilaginous skeleton
- Inner lining layer, which is mostly composed of mucus and a little skin.
The skeletal layer is composed of bone on the top and leads at the bottom to more subtle cartilages of the nose tip. There is no cartilage in the lower parts of the nose, including a large part of the nasal nostrils and alas, and it is basically formed of skin. Coming from the top to down, the skin plays more prominent role in shaping the nose. The skin reacts to these changes depending on its quality. The better, finer and more flexible skin texture tolerates a wider range of changes and allows the surgeon to make differences in bones and cartilages more freely. This is mostly true at the lower parts of the nose and its tip, which is more dependent on the flexibility of the skin to withstand changes in its underlying cartilage due to its complex form of skin.
By fleshy nose, we mean that the nose skin in the lower regions, i.e., the nose tip and the blade is worse, while in the bony nose, the skin in these areas has a better quality. Contrary to most patients understanding of a bony nose as the presence of a nasal hump, its correction is one of the easiest parts of rhinoplasty. Although its impact is very obvious, but the art of a good surgeon reveals itself in creating a beautiful nose tip. Although this depends on the surgeon skill, however, the skin quality of the lower parts of the nose and its tip is considered as an important factor in achieving better results. Regardless of the presence or absence of the hump, the worse quality of the skin reflects the presence of a fleshier nose. This means, in addition to having a large hump, a nose can have a bad skin quality on the nose tip, leading us to consider it as a fleshy nose, and vice versa, the nose may have not a big hump, and the high quality skin of its tip could classify it in the category bony noses. If the skin of a nose tip has an appropriate quality, the nose tip correction in the hands of a good surgeon can give a higher result. This type of nose is called bony nose, whether it has a big hump or not.
In other words, if the problems of nose are more related to its skin, the nose would be fleshier, and if the problems are related less to the skin and much more to the bony- cartilaginous layer, the nose would be bonier.
A good surgeon can fix almost all cartilage and bone problems. What makes the difference between the results of surgeries by a surgeon on two different patients is usually caused by the different quality of the two patients’ skin and different properties of the rest of their faces, which can have a significant impact on the representation of results.